PRACTICE 


W.  S.  PLAYPAIR,  M.D.,  F.R.O.P., 

PHYSICIAN-ACCOUCHEUR  TO  H.  I     AND  R.  H.  THE  DUCHESS  OP  EDINBURGH  J  PROFESSOR  OF  OBSTETRIC 

MEDICINE    IN  KINO'S  COLLEGE  ;    PHYSICIAN    FOR  THE    DISEASES  OF  WOMEN  AND  CHILDREN    TO 

KING'S  COLLEGE  HOSPITAL  ;  CONSULTING  PHYSICIAN  TO  THE  EVELINA  HOSPITAL  FOB 

CHILDREN  ;  EXAMINER  IN  MIDWIFERY  TO  THE  UNIVERSITY  OF  LONDON  ;  LATE 

EXAMINER    IN    MIDWIFERY  TO  THE    ROYAL    COLLEGE    OF  PHYSICIANS  | 

AXD  VICE-PRESIDENT  OF  THE  OBSTETRICAL  SOCIETY  OF  LONDON. 


WITH  NOTES  AND  ADDITIONS 


BY 

ROBEET    P.   HARRIS,  M.D. 


SECOND   AMERICAN 

FROM  THE 

SECOND   AND   REVISED   LONDON   EDITION. 


WITH  TWO  PLATES  AND  ONE  HUNDRED  AND  EIGHTY-TWO  ILLUSTRATIONS. 


PHILADELPHIA: 

HENRY     O .     LEA. 

1878. 


Entered  according  to  Act  of  Congress,  in  the  year  1878,  by 

HENRY    C.     LE  A, 
in  the  Office  of  the  Librarian  of  Congress,  at  Washington. 


COLLIXS,    PRINTER. 


TO 


T.  GAILLARD  THOMAS,  M.D., 

PROFESSOR  OF  OBSTETRICS 
IN  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  NEW  YORK. 


DEAR  DR.  THOMAS  : 

I  am  desirous  of  marking  my  gratitude  for  the  kind  reception  of  my 
book  in  America,  where  so  much  valuable  obstetric  work  has  been  done,  by 
associating  with  the  Second  Edition  the  name  of  one  whose  many  important 
contributions  to  the  branch  of  Medicine  of  which  it  treats  have  gained  for 
him  so  great  and  so  well-deserved  a  reputation.  I  could  wish  that  it  were 
more  worthy  of  the  honor  you  do  me  in  allowing  me  to  dedicate  it  to  you  ; 
but,  such  as  it  is,  I  beg  you  to  accept  it  as  a  mark  of  the  high  esteem  in 
which  you,  as  well  as  your  fellow  laborers  in  obstetric  science,  are  held  in 
the  mother  country. 

I  am,  very  faithfully  yours, 

W.  S.  PLAYFAIR. 

31  GEORGE  STREET,  HANOVER  SQUARE,  1878. 


PREFACE  TO  THE  SECOND  EDITION. 


Ix  presenting  a  Second  Edition  the  Author  has  very  gratefully  to 
acknowledge  the  favorable  reception  which  has  been  accorded  by 
the  Profession  to  his  work,  as  indicated  by  the  rapid  exhaustion  of 
an  unusually  large  impression.  He  trusts  that  the  revision  to 
which  the  book  has  been  subjected  may  render  it  still  more 
worthy  of  being  used  as  a  guide  in  the  study  of  the  important 
and  responsible  branch  of  medicine  of  which  it  treats.  He  has 
again  to  tender  his  cordial  thanks  to  his  colleague,  Dr.  HAYES,  for 
the  trouble  he  has  taken  in  assisting  him  in  passing  it  through  the 
press. 

31  GEORGE  STREET,  HANOVER  SQUARE, 
March,  1878. 


PREFACE  TO  THE  FIRST  EDITION. 


THOSE  who  have  studied  the  progress  of  Midwifery  know  that 
there  is  no  department  of  medicine  in  which  more  has  been  done 
of  late  years,  and  none  in  which  modern  views  of  practice  differ 
more  widely  from  those  prevalent  only  a  short  time  ago.  The 
Author's  object  has  been  to  place  in  the  hands  of  his  readers  an 
epitome  of  the  science  and  practice  of  midwifery  which  embodies 
all  recent  advances.  He  is  aware  that  on  certain  important  points 
he  has  recommended  practice  which  not  long  ago  would  have  been 
considered  heterodox  in  the  extreme,  and  which,  even  now,  will  not 
meet  with  general  approval.  He  has,  however,  the  satisfaction  of 
knowing  that  he  has  only  done  so  after  very  deliberate  reflection, 
and  with  the  profound  conviction  that  such  changes  are  right,  and 
that  they  will  stand  the  test  of  experience.  He  has  endeavored  to 
dwell  especially  on  the  practical  part  of  the  subject,  so  as  to  make 
the  work  a  useful  guide  in  this  most  anxious  and  responsible  branch 
of  the  profession.  .  It  is  admitted  by  all,  that  emergencies  and 
difficulties  arise  more  often  in  this  than  in  any  other  branch  of 
practice  ;  and  there  is  no  part  of  the  practitioner's  work  which 
requires  more  thorough  knowledge  or  greater  experience.  It  is, 
moreover,  a  lamentable  fact  that  students  generally  leave  their 
schools  more  ignorant  of  obstetrics  than  any  other  subject.  So  long 
as  the  absurd  regulations  exist,  which  oblige  the  lecturer  on  mid- 
wifery to  attempt  the  impossible  task  of  teaching  obstetrics  in  a 
short  three  months'  course — an  absurdity  which  has  over  and  over 
again  been  pointed  out — such  must  of  necessity  be  the  case.  This 
must  be  the  Author's  excuse  for  dwelling  on  many  topics  at  greater 


X  PREFACE    TO    THE    FIRST    EDITION. 

length  than  some  will  doubtless  think  their  importance  merits 
since  he  desires  to  place  in  the  hands  of  his  students  a  work  which 
may  in  some  measure  supply  the  inevitable  defects  of  his  lectures. 

Many  of  the  illustrations  are  copied  from  previous  authors,  while 
some  are  original.  The  following  quotation  from  the  preface  to 
Tyler  Smith's  "  Manual  of  Obstetrics"  will  explain  why  the  source 
of  the  copied  woodcuts  has  not  been  in  each  instance  acknowledged : 
"  When  I  began  to  publish,  I  determined  to  give  the  authority  for 
every  woodcut  copied  from  other  works;  .1  soon  found,  however, 
that  obstetric  authors  of  all  countries,  from  the  time  of  Mauri- 
ceau  downwards,  had  copied  each  other  so  freely  without  acknowl- 
edgment as  to  render  it  difficult  or  impossible  to  trace  the 
originals." 

The  Author  has  to  express  his  acknowledgments  to  many 
friends  for  their  kind  assistance  by  the  loan  of  illustrations  and 
otherwise,  and  more  especially  to  his  colleague,  Dr.  HAYES,  for 
his  valuable  aid  in  passing  the  work  through  the  press. 

31  GEORGE  STREET,  HAXOVEB  SQCARE, 
March,  1876. 


CONTENTS. 


PART  I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  ORGANS  CONCERNED  IN 

PARTURITION. 


CHAPTER  I. 

THE   BONY  PELVIS. 

PAGE 

Its  importance — Formation  of  Pelvis — The  os  innominatum  :  its  three  divisions — 
Separation  between  the  True  and  False  Pelvis — the  Sacrum  and  Coccyx — Me- 
chanical relations  of  the  Sacrum-r- Pelvic  articxilations  and  ligaments — Move- 
ments of  the  Pelvic  joints — The  Pelvis  as  a  whole — Differences  in  the  two  sexes 
— Measurements  of  the  Pelvis — Its  diameters,  planes,  and  axes — Development 
of  the  Pelvis — Soft  parts  in  connection  with  the  Pelvis  .  .  .  .  .25 

CHAPTER  II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function  :  1.  External  or  Copulative  ;  2.  Internal  or  Form- 
ative Organs — Mons  Veneris — Lalna  majora  and  minora — The  Clitoris — The 
vestibule  and  orifice  of  Urethra — Passing  of  the  female  catheter — Orifice  of 
Vagina — The  Hymen — The  glands  of  the  Vulva — The  Perineum — The  Vagina 
— The  Uterus  ;  its  position  and  anatomy— The  ligaments  of  the  Uterus — The 
Parovarium — The  Fallopian  Tubes — The  Ovaries — The  Graafian  Follicles,  and 
the  Ova 41 

CHAPTER  III. 

OVULATION  AND  MENSTRUATION. 

Functions  of  the  Ovary — Changes  in  the  Graafian  Follicle :  1.  Maturation  ;  2. 
Escape  of  the  Ovum — Formation  of  the  Corpus  Luteum — Quality  and  source  of 
the  Menstrual  blood — Theory  of  Menstruation — Purpose  of  the  Menstrual  loss 
—Vicarious  Menstruation — Cessation  of  Menstruation  .  .  .  .  .71 


xii  CONTENTS. 

PART   II. 

PREGNANCY. 


CHAPTER  I. 

CONCEPTION  AND  GENERATION. 

PAGE 

The  Semen — Site  and  mode  of  Impregnation — Changes  in  the  Ovum — Cleavage 
of  the  Yelk — The  Decidua  and  its  formation — Formation  of  the  Amnion — The 
Umbilical  Vesicle  and  Allantois — The  Liquor  Amnii  and  its  uses — The  Chorion 
— The  Placenta  :  its  formation,  anatomy,  and  functions  .....  84 

CHAPTER  II. 

THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS. 

Appearance  of  the  Foetus  at  various  stages  of  development — Anatomy  of  the  Foetal 
Head — The  Sutures  and  Fontanelles — Influence  of  Sex  and  Race  on  the  Foetal 
Head — Position  of  the  Fcetus  in  utero — Functions  of  the  Foetus — The  Foetal 
Circulation 107 

CHAPTER  III. 

PREGNANCY. 

Changes  in  the  form  and  dimensions  of  the  Uterus — Changes  in  the  Cervix — 
Changes  in  the  texture  of  the  Uterine  Tissues,  the  Peritoneal,  Muscular,  and 
Mucous  Coats — General  modifications  in  the  Body  produced  by  Pregnancy  .  123 

CHAPTER  IV. 

SIGNS  AND  DIAGNOSIS  OF  PREGNANCY. 

Signs  of  a  fruitful  Conception — Cessation  of  Menstruation — Sympathetic  disturb- 
ances :  Morning  Sickness,  etc. — Mammary  Changes — Enlargement  of  the  Ab- 
domen— Quickening — Intermittent  Uterine  contractions — Vaginal  Signs  of 
Pregnancy — Ballottement,  etc. — Auscultatory  Signs  of  Pregnancy — Fcetal  Pul- 
sations— Uterine  Souffle,  etc 133 

CHAPTER  V. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY SPURIOUS  PREGNANCY 

DURATION  OF  PREGNANCY SIGNS  OF  RECENT  DELIVERY. 

Adipose  enlargement  of  the  Abdomen — Distension  of  the  Uterus  by  retained 
Menses,  etc. — Congestive  enlargement  of  Uterus — Ascites — Uterine  and  Ovarian 
Tumors — Spurious  Pregnancy:  its  Causes,  Symptoms,  and  Diagnosis — The 
duration  of  Pregnancy — Sources  of  Fallacy — Methods  of  Predicting  Date  of  De- 
livery— Protraction  of  Pregnancy — Signs  of  recent  Delivery  ....  148 


CONTENTS.  Xlll 


CHAPTER  VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY,  SUPER- 
FETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED  LABOR. 

PAGE 

Plural  Births,  their  frequency:  Relative  frequency  in  different  Countries; 
Causes,  etc. — Super-fetation  and  Super-fecundation — Nature — Explanation — 
Objections  to  admission  of  such  cases — Their  possibility  admitted — Extra- 
Uterine  Pregnancy — Classification — Causes — Tubal  Pregnancies — Changes  in  the 
Fallopian  Tubes — Condition  of  Uterus — Progress  and  Termination — Diagnosis 
— Treatment — Abdominal  Pregnancy :  Description  ;  Diagnosis  ;  Treatment — 
Missed  Labor :  its  Symptoms,  Causes,  and  Treatment  .....  157 


CHAPTER  VII. 

THE  DISEASES  OF  PREGNANCY. 

Some  only  Sympathetic,  others  Mechanical  or  Complex  in  their  Origin — Derange- 
ments of  the  Digestive  Organs :  Excessive  Nausea  and  Vomiting ;  Diarrhoea ; 
Constipation  ;  Hemorrhoids  ;  Ptyalism  ;  Toothache  and  Caries  of  Teeth ;  Affec- 
tions of  Respiratory  Organs  ;  Dyspnoea,  etc. — Palpitation — Syncope — Anaemia 
and  Chlorosis — Albuminuria  ..........  183 

CHAPTER  VIII. 

THE  DISEASES  OF  PREGNANCY  (continued). 

Disorders  of  the  Nervous  System :  Insomnia ;  Headaches  and  Neuralgia ;  Paraly- 
sis ;  Chorea ;  Disorders  of  the  Urinary  Organs  ;  Retention  of  Urine  ;  Irritability 
of  the  Bladder;  Incontinence  of  Urine;  Phosphatic  Deposits;  Leucorrhoea; 
Effects  of  Pressure ;  Laceration  of  Veins  ;  Displacements  of  the  Gravid  Uterus  : 
Prolapse,  Anteversion,  Retroversion — Diseases  coexisting  with  Pregnancy ; 
Eruptive  Fevers  ;  Smallpox,  Measles,  Scarlet  Fever,  Continued  Fever;  Phthisis  ; 
Cardiac  Disease  ;  Syphilis  ;  Icterus  ;  Carcinoma ;  Pregnancy  complicated  with 
Ovarian  and  Fibroid  Tumors  ..........  196 

CHAPTER  IX. 

PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 

Pathology  of  the  Decidua — Hydrorrhea  Gravidarum — Pathology  of  the  Chorion  ; 
Vesicular  Degeneration,  Myxoma  Fibrosum — Pathology  of  the  Placenta :  Blood 
Extravasations,  Fatty  Degeneration,  etc. — Pathology  of  the  Umbilical  Cord — 
Pathology  of  the  Amnion,  Hydramnios  ;  Deficiency  of  Liquor  Amnii,  etc. — 
Pathology  of  the  Foetus :  Blood  Diseases  transmitted  through  the  Mother,  Small- 
pox, Measles,  and  Scarlet  Fever,  Intermittent  Fevers,  Lead-poisoning,  Syphilis, 
— Inflammatory  Diseases — Dropsies — Tumors — Wounds  and  Injuries  of  the 
Foetus — Intrauterine  Amputations — Death  of  the  Foetus  .....  212 


XIV  CONTEXTS. 

CHAPTER  X. 

ABORTION  AND  PREMATURE  LABOR. 

PAGE 

Importance  and  Frequency — Definition  and  Classification — Frequency — Recur- 
rence— Causes — Causes  Referable  to  Foetus — Changes  in  a  Dead  Ovum  retained 
in  Utero — Extravasations  of  Blood — Moles,  etc. — Causes  depending  on  Maternal 
State — Syphilis :  Causes  acting  through  Nervous  System,  Physical  Causes,  etc. 
— Causes  depending  on  Morbid  States  of  Uterus — Symptoms — Preventive  Treat- 
ment— Prophylactic  Treatment — Treatment  when  Abortion  is  inevitable — After- 
Treatment  .  229 


PART  III. 

LABOR. 


CHAPTER  I. 

THE  PHENOMENA  OF  LABOR. 

Causes  of  Labor — Mode  in  which  the  Expulsion  of  the  Child  is  effected — The 
Uterine  contraction — Mode  in  which  the  Dilatation  of  the  Cervix  is  effected — 
Rupture  of  the  Membranes — Character  and  source  of  Pains  during  Labor — 
Effect  of  Pains  on  Mother  and  Foetus — Division  of  Labor  into  Stages — Prepara- 
tory Stage — False  Pains — First  Stage — Second  Stage — Third  Stage — Mode  in 
which  the  Placenta  is  expelled — Duration  of  Labor 242 

CHAPTER  II. 

MECHANISM  OF  DELIVERY  IN  HEAD  PRESENTATIONS. 

Importance  of  Subject — Frequency  of  Head  Presentations — The  different  positions 
of  the  Head — First  Position — ^Division  of  Mechanical  Movements  into  Stages — 
Flexion — Rotation — Extension — External  Rotation — Second  Position — Third 
Position — Fourth  Position — Caput  Succedaneum — Alteration  in  shape  of  Head 
from  moulding 255 

CHAPTER  III. 

MANAGEMENT  OF  NATURAL  LABOR. 

Preparatory  Treatment — Dress  of  Patient  during  Pregnancy — The  Obstetric  Bag 
— Duties  on  first  visiting  Patient — False  Pains — Their  Character  and  Treatment 
— Vaginal  Examination — The  Position  of  Patient — Artificial  Rupture  of  Mem- 
branes— Treatment  of  Propulsive  Stage — Relaxation  of  the  Perineum — Treat- 
ment of  Lacerations — Expulsion  of  Child — Promotion  of  Uterine  Contraction — 
Ligature  of  the  Cord — Management  of  the  Third  Stage  of  Labor — Application  of 
the  Binder — After-Treatment .  268 


CONTENTS.  XV 

CHAPTER  IV. 

ANAESTHESIA  IN  LABOR. 

PAGE 

Agents  employed — Chloral:  its  Object  and  Mode  of  administration  —  Ether — 
Chloroform :  its  Use,  Objections  to,  and  Mode  of  administration  .  .  .  282 

CHAPTER  V. 

PELVIC  PRESENTATIONS. 

Frequency — Causes — Prognosis  to  Mother  and  Child — Diagnosis  by  Abdominal 
Palpation  and  by  Vaginal  Examination — Differential  Diagnosis  of  Breech,  Knee, 
and  Feet — Mechanism — Treatment — Management  of  Impacted  Breech  Presenta- 
tions . 286 

CHAPTER  VI. 

PRESENTATIONS  OF  THE  FACE. 

Erroneous  Views  formerly  held  on  the  Subject — Frequency — Mode  of  Production — 
Diagnosis — Mechanism — Four  Positions  of  the  Face — Description  of  Delivery 
in  First  Face  Position — Mento-Posterior  Positions  in  which  Rotation  does  not 
take  place — Prognosis — Treatment  .  .  .  .  .  .  .  .  .297 

CHAPTER  VII. 

DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS. 

Causes  of  Face  to  Pubis  Delivery — Mode  of  Treatment-^— Upward  Pressure  on 
Forehead — Downward  Traction  on  Occiput — Use  of  Forceps — Peculiarities  of 
Forceps  Delivery  ............  307 

CHAPTER  VIII. 

PRESENTATIONS  OF  SHOULDER,  ARM,  OR  TRUNK COMPLEX 

PRESENTATIONS PROLAPSE  OF  THE  FUNIS. 

Position  of  the  Foetus — Division  into  Dorso-Anterior  and  Dorso-Posterior  Posi — 
tions — Causes — Prognosis  and  Frequency — Diagnosis — Mode  of  distinguishing 
Position  of  Child  —  Differential  Diagnosis  of  Shoulder,  Elbow,  and  Hand — 
Mechanism — The  Two  possible  Modes  of  Delivery  by  the  Natural  Powers — 
Spontaneous  Version — Spontaneous  Evolution — Treatment — Complex  Presenta- 
tion :  Foot  or  Hand  with  Head,  Hand  and  Feet  together — Dorsal  Displacement 
of  the  Arm — Prolapse  of  the  umbilical  Cord — Frequency — Prognosis — Causes — 
Diagnosis — Postural  Treatment — Artificial  Reposition — Treatment  when  Repo- 
sition fails  .............  309 

CHAPTER  IX. 

PROLONGED  AND  PECIPITATE  LABORS. 

Evil  effects  of  Prolonged  Labor — Influence  of  the  Stage  of  Labor  in  Protraction — 
Delay  in  First  Stage  rarely  serious — Temporary  Cessation  of  Pains — Symptoms 


Xvi  CONTENTS. 

PAGE 

of  Protraction  in  the  Second  Stage — State  of  the  Uterus  in  Protracted  Labor — 
Cases  of  Protraction  due  to  Morbid  condition  of  the  expulsive  powers — Causes  of 
Protraction — Treatment — Oxytocic  remedies — Ergot  of  Rye,  etc. — Manual  Pres- 
sure— Instrumental  Delivery — Precipitate  Labor — Its  Causes  and  Treatment  .  324 

CHAPTER  X. 

LABOR  OBSTRUCTED  BY  FAULTY  CONDITION  OF  THE  SOFT  PARTS. 

Rigidity  of  the  Cervix  :  its  Causes,  Effects,  and  Treatment — Bands  and  Cicatrices 
in  the  Vagina — Extreme  rigidity  of  the  Perineum — Labor  complicated  with 
Tumor — Vaginal  Cystocele — Calculus — Hernial  Protrusions — (Edema  of  Vulva 
— Haematic  Effusions,  etc. 339 

CHAPTER  XI. 

DIFFICULT  LABOR  DEPENDING  ON  SOME  UNUSUAL  CONDITION  OF 
THE  FCETUS. 

Plural  Births,  Treatment  of — Locked  Twins — Conjoined  Twins — Intra-uterine 
Hydrocephalus  :  Its  Dangers,  Diagnosis,  and  Treatment — Other  dropsical  Effu- 
sions— Foetal  Tumors — Excessive  Development  of  Foetus  .....  353 

CHAPTER  XII. 

DEFORMITIES  OF  THE  PELVIS. 

Classification — Causes  of  Pelvic  Deformity — Rickets  and  Osteo-malacia — The 
Equally  enlarged  Pelvis — The  Equally  contracted  Pelvis — The  Undeveloped 
Pelvis — Masculine  or  Funnel-shaped  Pelvis — Contraction  of  Conjugate  Diameter 
of  the  Brim — Figure-of-Eight  deformity — Spondylolithesis — Narrowing  of  the 
Oblique  Diameters — Obliquely  contracted  Pelvis — Kyphotic  Pelvis — Robert's 
Pelvis — Deformity  from  old-standing  Hip-joint  disease — Deformity  from  Tumors, 
Fractures,  etc. — Effects  of  Contracted  Pelvis  on  Labor — Risks  to  the  Mother  and 
Child — Mechanism  of  Delivery  in  Head  Presentation  ;  «,  in  Contracted  Brim ; 
b,  in  Generally  contracted  Pelvis — Diagnosis — External  Measurements — Internal 
Measurements — Mode  of  estimating  the  Conjugate  diameter  of  the  brim — Mode 
of  Diagnosing  the  Oblique  Pelvis — Treatment — The  Forceps — Turning — The 
Induction  of  Premature  Labor — Induction  of  Abortion  .....  366 

CHAPTER  XIII. 

HEMORRHAGE  BEFORE  DELIVERY  :    PLACENTA  PRJEVIA. 

i 

Definition — Causes — Symptoms — Sources  and  Causes  of  Hemorrhage — Prognosis — 
Treatment 388 

CHAPTER  XIV. 

HEMORRHAGE  FROM    SEPARATION  OF  A  NORMALLY  SITUATED  PLACENTA. 
Causes  and  Pathology — Symptoms  and  Diagnosis — Prognosis — Treatment    .         .  399 


CONTENTS.  XV11 

CHAPTER  XV. 

HEMORRHAGE  AFTER  DELIVERY. 

PAGE 

Its  frequency — Generally  a  preventable  accident — Causes — Nature's  method  of 
Controlling  Hemorrhage — Uterine  Contraction — Thrombosis — Secondary  Causes 
of  Hemorrhage — Irregular  Uterine  Contraction — Placeiital  Adhesions — Consti- 
tutional Predisposition  to  Flooding — Symptoms — Preventive  treatment — Cura- 
tive treatment — Secondary  post-partum  Hemorrhage — Its  Causes  and  Treatment  402 

CHAPTER  XVI. 

RUPTURE  OF  THE  UTERUS,  ETC. 

Its  Fatality — Seat  of  Eupture — Causes,  predisposing  and  exciting — Symptoms — 
Prognosis — Treatment :  when  the  Foetus  remains  in  Utero ;  when  the  Foetus 
has  escaped  from  the  Uterus — Recapitulation — Lacerations  of  the  vagina — Vesico 
and  Recto-vaginal  Fistulse — Their  mode  of  Formation — Treatment  .  .  .  419 

CHAPTER  XVII. 

INVERSION  OF  THE  UTERUS. 

Division  into  Acute  and  Chronic  forms — Description — Symptoms — Diagnosis — 
Mode  of  production — Treatment  .  .  .  .  .  .  .  ,  429 


PAET  IY. 

OBSTETRIC  OPERATIONS. 


CHAPTER  I. 

INDUCTION  OF  PREMATURE  LABOR. 

History — Objects — May  be  performed  either  on  account  of  the  Mother  or  Child — 
Modes  of  Inducing  Labor — Puncture  of  Membranes — Administration  of  Oxyto- 
cics — Means  acting  indirectly  on  the  Uterus — Dilatation  of  Cervix — Separation 
of  Membranes — Vaginal  and  Uterine  douches — Introduction  of  Flexible  Ca- 
theter   435 

CHAPTER  II. 

TURNING. 

History — Turning  by  External  Manipulation — Object  and  Nature  of  the  Opera- 
tion— Cases  Suitable  for  the  operation — Statistics  and  Dangers — Method  of 
performance — Cephalic  Version — Method  of  performance — Podalic  Version — 
Position  of  Patient — Administration  of  Anaesthetics — Period  when  the  opera- 
tion should  be  undertaken — Choice  of  Hand  to  be  used — Turning  by  Bi-polar 
method — Turning  when  the  Hand  is  introduced  into  the  Uterus — Turning  in 
Abdomino-anterior  Positions — Difficult  cases  of  Arm  Presentation  .  .  .  442 
2 


XVlii  CONTENTS. 

CHAPTER  III. 

THE  FORCEPS. 

PAOE 

Frequent  use  of  the  Forceps  in  Modern  practice — Description  of  the  Instrument — 
The  Short  Forceps — Its  Varieties — The  Long  Forceps — Suitable  to  all  cases 
alike — Action  of  the  Instrument — Its  power  as  a  Tractor,  Lever,  and  Compres- 
sor— Preliminary  considerations  before  operation — Use  of  Anaesthetics — De- 
scription of  the  Operation — Low  Forceps  Operation — High  Forceps  Operation — 
Possible  Dangers  of  Forceps  Delivery — Possible  Risks  to  the  Child  .  .  .458 

CHAPTER  IV. 

THE  VECTIS THE  FILLET. 

Nature  of  the  Vectis — Its  use  as  a  Lever  or  Tractor — Cases  in  which  it  is  appli- 
cable— Its  use  as  a  Rectifier  of  Malpositions — The  Fillet — Nature  of  the  Instru- 
ment— Objections  to  its  use  > 482 

CHAPTER  V. 

OPERATIONS  INVOLVING  THE  DESTRUCTION  OF  THE  F03TUS. 

Their  Antiquity  and  History — Division  of  Subject — Nature  of  Instruments  em- 
ployed —  Perforator — Crotchet — Craniotomy  Forceps — Cephalotribe — Forceps- 
saw — Ecraseur — Cases  requiring  Craniotomy — Method  of  Perforation — Extrac- 
tion of  the  Head — Comparative  merits  of  Cephalotripsy  and  Craniotomy — 
Extraction  by  the  Craniotomy  Forceps — Extraction  of  the  Body — Embryotomy — 
Decapitation  and  Evisceration 484 

CHAPTER  VI. 

THE  C^ESAREAN  SECTION SYMPHYSEOTOMY  AND  LAPARO-ELYTROTOMY. 

History  of  the  Operation — Statistics — Results  to  Mother  and  Child — Causes  re- 
quiring the  Operation — Post-mortem  Caesarean  Section — Causes  of  Death  after 
the  Caesarean  Section — Preliminary  Preparations — Description  of  the  Operation 
— Subsequent  Management — Substitutes  for  the  Caesarean  Section — Symphyse- 
otomy — Laparo-elytrotomy 499 

CHAPTER  VII. 

THE  TRANSFUSION  OF  BLOOD. 

History — Nature  and  Object  of  the  Operation — Use  of  Blood  taken  from  the  Lower 
Animals — Difficulties  from  Coagulation  of  Fibrine — Modes  of  Obviating  them — 
Immediate  Transfusion — Addition  of  Chemical  Agents  to  prevent  Coagulation — 
Defibrination  of  the  Blood — Statistical  Results — Possible  Dangers  of  the  Opera- 
tion— Cases  suitable  for  Transfusion — Description  of  the  Operation — Effects  of 
Successful  Transfusion — Secondary  Effects  of  Transfusion.  ....  514 


CONTENTS.  XIX 

PAET    Y. 

THE  PUERPERAL  STATE. 


CHAPTER  I. 

THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT. 

PAOE 

Importance  of  Studying  the  Puerperal  State — The  Mortality  of  Childbirth — Alte- 
rations in  the  Blood  after  Delivery — Condition  after  Delivery — Nervous  Shock 
— Fall  of  the  Pulse — The  Secretions  and  Excretions — Secretion  of  Milk — 
Changes  in  the  Uterus  after  Delivery — The  Lochia — The  After-pains — Manage- 
ment of  Women  after  Delivery — Treatment  of  Severe  After-pains — Diet  and 
Regimen 523 

CHAPTER  II. 

MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration  after  the  Birth  of  the  Child — Apparent  Death  of 
the  new-horn  Child — Its  Treatment — Washing  and  Dressing  the  Child — Ap- 
plication of  the  Child  to  the  Breast — The  Colostrum  and  its  Properties — Secre- 
tion of  Milk — Importance  of  Nursing — Selection  of  a  Wet-nurse — Management 
of  Lactation — Diet  and  Regimen  of  Nursing  Women — Period  of  Weaning — 
Disorders  of  Lactation — Means  of  Arresting  the  Secretion  of  Milk — Defective 
Secretion  of  Milk — Depressed  Nipples — Fissures  and  Excoriations  of  the  Nipples 
— Excessive  Flow  of  Milk — Mammary  Abscess — Hand-feeding — Causes  of  Mor- 
tality in  Hand-feeding — Various  kinds  of  Milk — Method  of  Hand-feeding  .  533 

CHAPTER  III. 

PUERPERAL  ECLAMPSIA. 

Its  Doubtful  Etiology — Premonitory  Symptoms — Symptoms  of  the  attack — Con- 
dition between  the  Attacks — Relation  of  the  attacks  to  Labor — Results  to 
Mother  and  Child — Pathology — Treatment — Obstetric  Management  .  .  .  550 

CHAPTER  IV. 

PUERPERAL  INSANITY. 

Classification — Proportion  of  Various  forms — Insanity  of  Pregnancy — Predispos- 
ing Causes — Period  of  Pregnancy  at  which  it  occurs — Type  of  Insanity — 
Prognosis — Transient  Mania  during  Delivery — Puerperal  Insanity  (Proper) — 
Type  of  Insanity — Causes — Theory  of  its  dependence  on  a  Morbid  State  of  the 
Blood — Objections  to  the  theory — Prognosis — Post-mortem  signs — Duration — 
Insanity  of  Lactation — Type — Symptoms — Of  Mania — Of  Melancholia — Treat- 
ment— Question  of  Removal  to  Asylum — Treatment  during  Convalescence  .  559 


XX  CONTENTS. 

CHAPTER  V. 

PUERPERAL    SEPTICAEMIA. 

PAOB 

Differences  of  opinion — Confusion  from  this  cause — Modern  view  of  this  Disease — 
History — Its  Mortality  in  Lying-in  Hospitals — Numerous  Theories  as  to  its 
Nature — Theory  of  Local  Origin — Theory  of  an  Essential  Zymotic  Fever — 
Theory  of  its  identity  with  Surgical  Septicaemia — Nature  of  this  view — 
Channels  through  which  Septic  Matter  may  be  absorbed — Character  and  Origin 
of  Septic  Matter  often  obscure — Division  into  Auto-genetic  and  Hetero-genetic 
cases — Sources  of  Self-infection — Sources  of  Hetero-genetic  Infection — Influence 
of  Cadaveric  Poison — Infection  from  Erysipelas — Infection  from  other  Zymotic 
Diseases — Contagion  from  other  Puerperal  Patients — Mode  in  which  the  Poison 
may  be  conveyed  to  the  Patient — Conduct  of  the  Practitioner  in  relation  to  the 
Disease — Nature  of  the  Septic  Poison — Local  changes  resulting  from  the  ab- 
sorption of  Septic  Material — Channels  through  which  Systemic  Infection  is 
produced — Pathological  Phenomena  observed  after  general  Blood  Infection — 
Four  principal  Types  of  Pathological  Change — Intense  cases  without  marked 
Post-mortem  Signs — Cases  characterized  by  Inflammation  of  the  Serous  Mem- 
branes— Cases  characterized  by  the  impaction  of  Infected  Emboli,  and  Secondary 
Inflammation  and  Abscess — Description  of  the  Disease — Duration — Varieties  of 
Symptoms  in  different  cases — Symptoms  of  Local  Complications — Treatment  .  570 

CHAPTER  VI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Puerperal  Thrombosis  and  its  Results — Conditions  which  favor  Thrombosis — Con- 
ditions which  favor  Coagulation  in  the  Puerperal  State — Distinction  between 
Thrombosis  and  Embolism — Is  primary  Thrombosis  of  the  Pulmonary  Arteries 
possible? — History — Symptoms  of  Pulmonary  Obstruction — Is  recovery  pos- 
sible ? — Causes  of  Death — Post-mortem  appearances — Treatment  .  .  .  594 

CHAPTER  VII. 

PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM. 
Causes — Symptoms — Treatment 605 

CHAPTER  VIII. 

OTHER  CAUSES  OF  SUDDEN  DEATH  DURING  LABOR  AND  THE  PUERPERAL 

STATE. 

Organic  and  Functional  causes — Idiopathic  Asphyxia — Pulmonary  Apoplexy — 
Cerebral  Apoplexy — Syncope— Shock  and  Exhaustion — Entrance  of  Air  into 
the  Veins 597 

CHAPTER  IX. 

PERIPHERAL  VENOUS  THROMBOSIS  (SYN.  :  CRURAL  PHLEBITIS PHLEGMASIA 

DOLENS ANASARCA  SEROSA (EDEMA  LACTEUM WHITE  LEG,  ETC.). 

Nature — Symptoms— History  and  Pathology— Anatomical  form  of  the  Thrombi 
in  the  Veins — Detachment  of  Emboli — Treatment  .  .609 


CONTENTS.  XXI 

CHAPTER  X. 

PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS. 

PACJK 

Two  Forms  of  Disease — Variety  of  Nomenclature — Importance  of  Differential 
Diagnosis — Etiology — Connection  with  Septicaemia — Seat  of  Inflammation — 
Relative  Frequency  of  the  two  forms  of  Disease — Symptomatology — Results  of 
Physical  Examination — Terminations — Prognosis — Treatment  .  .  .  616 


[APPENDIX. 

The  Intravenous   Injection   of  Fresh  Milk,   as  an  Improved  Substitute  for  the 
Transfusion  of  Blood        ...........  625] 

INDEX  .  629 


2* 


ILLUSTRATIONS. 


Section  of  a  Frozen  Body  in  the  last  months  of  Pregnancy  (after  Branne).  Illus- 
trating the  Relations  of  the  Uterus  to  the  surrounding  Parts,  and  the  attitude 
of  the  Foetus,  which  is  lying  in  the  second  Cranial  Position  .  .  Plate  I 

Section  of  a  Frozen  Body  at  the  termination  of  the  first  stage  of  Labor  (after 
Braune).  The  bag  of  membranes  is  still  unbroken,  the  cervix  is  fully  dilated, 
and  the  head  (in  the  second  position)  is  in  the  pelvic  cavity  .  .  Plate  II. 

FIG.  PAOB 

1.  Os  innominatum    ............  26 

2.  Sacrum  and  Coccyx        ...........  27 

3.  Section  of  Pelvis  and  heads  of  Thigh-bones,  showing  the  Suspensory  Action 

of  the  Sacro-iliac  Ligaments.     (After  Wood.)    ......  29 

4.  Outlet  of  Pelvis 32 

5.  The  Female  Pelvis 32 

6.  The  Male  Pelvis 33 

7.  Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Conjugate  Diameters  34 

8.  Transverse  section  of  Pelvis,  showing  the  Diameters    .....  34 

9.  Planes  of  the  Pelvis,  with  Horizon 36 

10.  Axes  of  the  Pelvis 37 

11.  Representing  general  Axis  of  the  Parturient  Canal,  including  the  Uterine 

Cavity  and  Soft  Parts .38 

12.  Side  view  of  Pelvis 38 

13.  Pelvis  of  a  Child 39 

14.  Vascular  Supply  of  Vulva.     (After  Kobelt.) 45 

15.  Longitudinal  section  of  Body,  showing  Relation  of  Generative  Organs  .  46 

16.  Transverse  section  of  Body,  showing  Relations  of  the  Fundus  Uteri     .         .  48 

17.  Transverse  section  of  Uterus 49 

18.  Uterus  and  Appendages  in  an  Infant     ........  49 

19.  Portion  of  Interior  of  Cervix.     (Enlarged  nine  diameters.)  ....  51 

20.  Muscular  Fibres  of  unimpregnated  Uterus.     (After  Farre.)          ...  52 

21.  Developed  Muscular  Fibres  from  the  Gravid  Uterus.     (After  Wagner.)         .  52 

22.  Lining  Membrane  of  Uterus,  showing  network  of  Capillaries  and  Orifices  of 

Uterine  Glands.     (After  Farre.)        .         .         .         .  .         .         .54 

23.  The  Course  of  the  Glands  in  the  fully  developed  Mucous  Membrane  of  the 

Uterus.     (After  Williams.)       .  54 

24.  Villi  of  Os  Uteri  stripped  of  Epithelium 55 

25.  Villi  of  Uterus,  covered  with  Pavement  Epithelium  and  containing  Looped 

Vessels.     (After  Tyler  Smith  and  Hassall.) 56 

26.  Bifid  Uterus.     (After  Farre.) 58 

27.  Adult  Parovarium,  Ovary,  and  Fallopian  Tube.     (After  Kobelt.)          .         .  59 

28.  Posterior  view  of  Muscular  and  Vascular  arrangements.     (After  Rouget.)   .  60 

29.  Fallopian  Tube  laid  open.     (After  Richard.) 62 


ILLUSTRATIONS. 

na.  PAOB 

30.  Ovary  enlarged  under  Menstrual  Nisus          .......  64 

31.  Longitudinal  Section  of  Adult  Ovary.     (After  Farre.) 65 

32.  Section  through  the  cortical  part  of  the  Ovary.     (After  Turner.)          .         .  66 

33.  Vertical  Section  through  the  Ovary  of  the  Human  Foetus.     (After  Foulis.)  66 

34.  Diagramatic  Section  of  Graafian  Follicle 67 

35.  Bulb  of  Ovary 69 

36.  Mammary  Gland   ............  70 

37.  Section  of  Ovary,  Showing  Corpus  Luteum  three  weeks  after  Menstruation. 

(After  Dalton.) 74 

38.  Corpus  Luteum  at  the  fourth  month  of  Pregnancy.     (After  Dalton.)    .         .  75 

39.  Corpus  Luteum  of  Pregnancy  at  Term.     (After  Dalton.)      ....  75 

40.  Sperm  Cells  and  Nuclei 84 

41.  Ovum  of  Rabbits  containing  Spermatozoa 86 

42.  Formation  of  the  "  Polar  Globule  " 87 

43.  Segmentation  of  the  Yelk 88 

44.  Formation  of  the  Blastodermic  Membrane.     (After  Joulin.)           ...  89 

45.  Aborted  Ovum  (of  about  forty  days),  showing  the  Triangular  Shape  of  the 

Decidua  (which  is  laid  open),  and  the  Aperture  of  the  Fallopian  Tube. 

(After  Coste.) 91 

46.  \ 

47.  >  Formation  of  the  Decidua.     (After  Dalton.)      ......  91 

48.  7 

49.  An  Ovum  removed  from  the  Uterus,  and  part  of  the  Decidua  Vera  cut  away. 

(After  Coste.) 92 

50.  Diagram  of  Area  Germinativa,  showing  the  primitive  trace  and  Area  Pel- 

lucida 94 

51.  Development  of  the  Amnion          .........  95 

52.  Development  of  the  Umbilical  Vesicle  and  Amnion       .....  96 

53.  An  Embryo  of  about  twenty-five  days  laid  open.     (After  Coste.)           .         .  96 

54.  Development  of  the  Chorion          .........  97 

55.  Placental  Villus,  greatly  magnified.     (After  Joulin.)    .....  102 

56.  Terminal  Villus  of  Foatal  Tuft,  minutely  Injected.     (After  Farre.)       .         .  103 

57.  Diagram  representing  a  Vertical  Section  of  the  Placenta.     (After  Dalton.)  .  103 

58.  Diagram  illustrating  the  Mode  in  which  a  Placental  Villus  derives  a  Cover- 

ing from  the  Vascular  System  of  the  Mother.     (After  Priestley.)      .         .  104 

59.  The  Extremity  of  a  Placental  Villus.     (After  Goodsir.)        ....  104 

60.  Anterior  and  Posterior  Fontanelles Ill 

61.  Bi-parietal  diameter,  Sagittal  and  Lambdoidal  Sutures,  with  Posterior  Fon- 

tanelle Ill 

62.  Diameters  of  the  Foetal  Skull Ill 

63.  Mode  of  ascertaining  the  Position  of  the  Foetus  by  Palpation        .         .         .  114 

64.  Diagram  illustrating  the  Effect  of  Gravity  on  the  Foetus.  (After  Duncan.)  .  115 

65.  Illustrating  the  greater  Mobility  of  the  Foetus  and  the  larger  relative  amount 

of  Liquor  Amnii  in  Early  Pregnancy.     (After  Duncan.)          .         .         .  116 

66.  Diagram  of  Foetal  Heart.     (After  Dalton.) 119 

67.  Diagram  of  Heart  of  Infant.     (After  Dalton.) 121 

68.  Size  of  Uterus  at  various  Periods  of  Pregnancy 124 

69.  -\ 

70.  I   Supposed  Shortening  of  the  Cervix  at  the  third,  sixth,  seventh,  and  nine 

71.  [       mouths  of  Pregnancy,  as  figured  in  Obstetric  works    ....  126 

72.  J 


ILLUSTRATIONS.  XXV 

FIO.  .  PAGE 

73.  Cervix  of  a  Woman   Dying  in  the  eighth  Month  of  Pregnancy.     (After 

Duncan.)          ............     127 

74.  Appearance  of  the  Areola  in  Pregnancy       .......     137 

75.  Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  Reflexa 

during  the  early  Months  of  Pregnancy.     (After  Coste.)  ....     163 

76.  Tubal  Pregnancy,  with  the  Corpus  Luteum  in  the  Ovary  of  the  opposite 

side  .         .         .         .         .         .         .         .         .         •         •         •         .166 

77.  Tubal  Pregnancy.     (From  a  specimen  in  the  Museum  of  King's  College.)   .     167 

78.  Extra-uterine  Pregnancy  at  term  of  the  Tubo-Ovarian  Variety.     (After 

a  case  of  Dr.  A.  Sibley  Campbell's.)         .......     169 

79.  Uterus  and  Foetus  in  a  case  of  Abdominal  Pregnancy  ....     175 

80.  Lithopsedion.     (From  a  preparation  in  the  Museum  of  the  Royal  College  of 

Surgeons.)        ............     176 

81.  Contests  of  the  Cyst  in  Dr.  Oldham's  case  of  Missed  Labor          .         .         .182 

82.  Hypertrophied  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal 

Portion.     (After  Duncan.)       .         .         .         .         .         .         .         .         .  213 

83.  Imperfectly  developed  Decidua  Vera,  with  the  Ovum.     (After  Duncan.)    .  214 

84.  Hydatiform  Degeneration  of  the  Chorion     .         .         .         .         .         .         .215 

85.  Double  Placenta,  with  Single  Cord 219 

86.  Fatty  Degeneration  of  the  Placenta 220 

87.  Knots  in  tlie  Umbilical  Cord 221 

88.  Intra-uterine  Amputation  of  both  Arms  and  Legs         .....  226 

89.  An  apoplectic  Ovum,  with  Blood  effused  in  masses  under  the  Foetal  Surface 

of  the  Membranes    .         .         .         .         .         .         .         .         .         .         •     231 

90.  Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membranes     .         .         .     232 

91.  Mode  in  which  the  Placenta  is  Naturally  Expelled.     (After  Duncan.)         .     253 

92.  Attitude  of  Child  in  first  position.     (After  Hodge.) 258 

93.  First  Position :  Movement  of  Flexion 259 

94.  First  Position  :  Occiput  in  Cavity  of  Pelvis.     (After  Hodge.)       .         .         .260 

95.  First  Position :  Occiput  at  Outlet  of  Pelvis.     (After  Hodge.)       .         .         .261 

96.  First  Position :  Head  Delivered.     (After  Hodge.) 263 

97.  External  Rotation  of  Head  in  first  position.     (After  Hodge.)        .         .         .     263 

98.  Third  Position  of  Occiput  at  Brim  of  Pelvis 264 

99.  Fourth  Position  of  Occiput  at  Pelvic  Brim 267 

100.  Examination  during  the  First  Stage  of  Labor 272 

101.  Mode  of  effecting  Relaxation  of  the  Perineum 276 

102.  Usual  Method  of  Removing  the  Placenta  by  Traction  on  the  Cord         .         .  279 

103.  Illustrating  Expression  of  the  Placenta 280 

104.  First,  or  left  Sacro-cotyloid  position  of  the  Breech 290 

105.  Passage  of  the  Shoulders  and  partial  Rotation  of  the  Thorax         .         .         .  291 

106.  Descent  of  the  Head 292 

107.  Second  position  in  Face  Presentation 300 

108.  Rotation  Forwards  of  Chin 302 

109.  Passage  of  the  Head  through  the  External  Parts  in  Face  Presentation         .  302 

110.  Illustrating  the  position  of  the  Head  when  Forward  Rotation  of  the  Chin 

does  not  take  place 303 

111.  Dorso-anterior  Presentation  of  the  Arm 311 

112.  Dorso-posterior  Presentation  of  the  Arm 311 

113.  Commencing  Spontaneous  Evolution    ........  316 

114.  Spontaneous  Evolution  further  Advanced 316 

115.  Dorsal  Displacement  of  the  Arm          .         .  318 


XXVI  ILLUSTRATIONS. 


116.  Dorsal  Displacement  of  the  Arm  in  Footling  Presentations.    (After  Barnes.)  339 

117.  Prolapse  of  the  Umbilical  Cord 320 

118.  Postural  Treatment  of  Prolapse  of  the  Cord 322 

119.  Braun's  Apparatus  for  Replacing  the  Cord 323 

120.  Labor  complicated  by  Ovarian  Tumor          .......  345 

121.  Twin  Pregnancy,  Breech  and  Head  presenting 353 

122.  Head  Locking,  both  Children  presenting  Head  first.     (After  Barnes)          .  355 

123.  Head  Locking,  first  Child  coming  Feet  first ;    Impaction  of  Heads  from 

wedging  in  Brim.     (After  Barnes)  ........  357 

124.  Labor  impeded  by  Hydrocephalus       ........  3(52 

125.  Adult  Pelvis  retaining  its  Infantile  Type 369 

126.  Rickety  Pelvis,  with  backward  depression  of  Symphysis  Pubis            .         .  371 

127.  Flatness  of  Sacrum,  with  narrowing  of  Pelvic  Cavity           ....  371 

128.  Pelvis  deformed  by  Spondylolithesis.     (After  Kilian)          .         .         .         .371 

129.  Osteo-malacic  Pelvis 373 

130.  Extreme  degree  of  Osteo-malacic  Deformity          ......  373 

131.  Obliquely  Contracted  Pelvis.     (After  Duncan)   .  *      .  .         .         .374 

132.  Robert's,  or  double  obliquely  Contracted  Pelvis 375 

133.  Bony  Growth  from  Sacrum  obstructing  the  Pelvic  Cavity   ....  375 

134.  Greenhalgh's  Pelvimeter 380 

135.  Section  of  Foetal  Cranium,  showing  its  Conical  Form           ....  384 

136.  Showing  the  greater  Breadth  of  the  biparietal  Diameter  of  the  Foetal  Cra- 

nium.     (After  Simpson)          .........  384 

137.  Showing  the  greater  Space  for  the  biparietal  Diameter  in  certain  Cases  of 

Deformity.     (After  Simpson) 384 

138.  Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta         .  406 

139.  Partial  Inversion  of  the  Fundus 430 

140.  Illustrating  the  Commencement  of  Inversion  at  the  Cervix.    (After  Duncan)  432 

141.  Barnes's  Bag  for  Dilating  the  Cervix            .......  439 

142.  First  Stage  of  Bi-polar  Version 449 

143.  Second  Stage  of  Bi-polar  Version          ........  450 

144.  Third  Stage  of  Bi-polar  Version 450 

145.  Fourth  Stage  of  Bi-polar  Version 451 

146.  Seizure  of  the  Feet  when  the  Hand  is  introduced  into  the  Uterus         .         .  453 

147.  Drawing  down  of  the  Feet  and  Completion  of  Version          ....  454 

148.  Showing  the  Completion. of  Version.     (After  Barnes)          ....  455 

149.  Showing  the  Use  of  the  Right  Hand  in  Abdomino-auterior  positions    .         .  456 

150.  Denman's  Short  Forceps      ..........  459 

151.  Zeigler's  Forceps 460 

152.  Simpson's  Forceps        ...........  461 

153.  Tarnier's  Forceps         .         . 462 

154.  Position  of  Patient  for  Forceps  Delivery,  and  Mode  of  Introducing  the 

Lower  Blade 466 

155.  Introduction  of  the  Upper  Blade 468 

156.  Forceps  in  position;  Traction  in  the  Axis  of  the  Brim,  downwards  and 

backwards 469 

157.  Last  Stage  of  Extraction ;  the  Handles  of  the  Forceps  turned  upwards 

towards  the  Mother's  Abdomen        .         .         .         .         .         .         .         .  470 

[158.  Hodge  Forceps 474] 

[159.  Wallace      "              475] 

[160.  Davis           "              475] 


ILLUSTRATIONS.  XXV11 


[161.  Elliot  Forceps  476] 

[162.  Sawyer     "  477] 

[163.  Application  of  Forceps  at  Inferior  Strait    .......  478] 

[164.  Application  of  Forceps  in  the  Head  at  Superior  Strait,  the  left  Blade  held 

in  place  by  an  Assistant         .........  480] 

[165.  Direction  of  Forceps  as  Head  is  being  Delivered          .....  481] 

166.  Vectis  with  Hinged  Handle 483 

167.  Wilmot's  Fillet 484 

168.  -j 

169.  >  Various  forms  of  Perforators    .........     486 

170.  ) 

171  &  172.  Crotchets 487 

173.  Craniotomy  Forceps 488 

174.  Simpson's  Cranioclast  ..........     488 

175.  Hick's  Cephalotribe 489 

176.  Perforation  of  the  Skull 492 

177.  Foetal  Head  crushed  by  the  Cephalotribe    .......     495 

[178.  Straight  Craniotomy  Forceps     .         .         .         .         .         .         .         .         .496] 

[179.  Curved  "  " 496] 

180.  Method  of  Transfusion  by  Aveling's  Apparatus  .....     521 

181.  Section  of  a  Uterine  Sinus  from  the  Placental  Site  nine  weeks  after  delivery. 

(After  Williams) 528 

182.  Haye's  Tube  for  Intra-uterine  Injections     .......     588 


P  L  A  T  E    J 


BUddar 


ditori 


Section  of  a  Frozen  Body  iu  the  last  mouth  of  Pregnancy  (after  Braune),  illustrating  the  Relations  of  the 
Uterus  to  the  mirronnding  parts,  and  the  Attitude  of  the  Fcetim,  which  is  lying  in  the  Second  Cranial 
Position. 


P  L  A  T  E    I  I . 


Pancreas 


Stomach 


Coeliac  A. 

Sup.  Hcsrnt.A 
V.  Portia 


Kit.  Os  Uteri—  - 


Ure 


Ext.  Os  Uteri 


Rectum 


Liquor  Amnil 


i-tioii  of  a  Frozen  Body  at  the  Termination  of  the  First  Stage  of  Labor  (after  Braune).  The  Bag  of  Mem- 
branes is  still  unbroken,  the  Cervix  is  fully  dilated,  and  the  Head  (in  the  second  position)  is  in  the  Pelvic 
Gavitr. 


THE  SCIENCE  AND  PRACTICE 


OF 


MIDWIFERY 


PART  I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  ORGANS  CONCERNED 
IN  PARTURITION. 


CHAPTER  I. 

ANATOMY  OF  THE  PELVIS. 

THE  pelvis  is  the  bony  basin  situated  between  the  trunk  and  the 
lower  extremities.  To  the  obstetrician  its  study  is  of  paramount 
importance,  for  it  not  only  contains,  in  the  unimpregnated  state,  all 
the  organs  connected  with  the  function  of  reproduction,  but  through 
its  cavity  the  foetus  has  to  pass  in  the  process  of  parturition.  An 
accurate  knowledge,  therefore,  of  its  anatomical  formation  may  be 
said  to  be  the  very  alphabet  of  obstetrics,  without  which  no  one  can 
practise  midwifery,  either  with  satisfaction  to  himself,  or  safety  to 
his  patient. 

In  a  treatise  on  obstetrics,  however,  any  detailed  account  of  the 
purely  descriptive  anatomy  of  the  pelvis  would  be  out  of  place.  A 
knowledge  of  that  must  Mk  taken  for  granted,  and  it  is  only  necessary 
to  refer  to  those  points  which  have  a  more  or  less  direct  bearing  on 
the  study  of  its  obstetrical  relations. 

The  pelvis  is  formed  of  four  bones.  On  either  side  are  the  osscr 
innominata,  joined  together  by  the  sacrum;  to  the  inferior  extremity 
of  the  sacrum  is  attached  the  coccyx,  which  is,  in  fact,  its  continuation. 

The  os  innominatum  (Fig.  1)  is  an  irregularly  shaped  bone  origi- 
nally formed  of  three  distinct  portions,  the  ilium,  the  ischium,  and 
the  pubes,  which  remain  separated  from  each  other  up  to  and  beyond 
the  period  of  puberty.  They  are  united  at  the  acetabulum  by  a 
Y-shaped  cartilaginous  junction,  which  does  not,  as  a  rule,  become 
ossified  until  about  the  twentieth  year.  The  consequence  is  that  the 
pelvis,  during  the  period  of  growth,  is  subject  to  the  action  of  various 
mechanical  influences  to  a  far  greater  extent  than  in  adult  life;  and 
3 


26  GROANS    CONCERNED    IN    PARTURITION. 

these,  as  we  shall  presently  see,  have  an  important  effect  in  deter- 
mining the  form  of  the  bones.  The  external  surface  and  borders  of 
the  os  innominatum  are  chiefly  of  obstetric  interest  from  giving 
attachment  to  muscles,  many  of  which  have  an  important  accessory 
influence  on  parturition,  such  as  the  muscles  forming  the  abdominal 
wall,  which  are  attached  to  its  crest,  and  those  closing  its  outlet  and 

FIG.  1. 


Os  Innominatuui. 


forming  the  perineum,  which  are  attached  to  the  tuberosity  of  the 
ischium.  On  the  anterior  and  posterior  extremities  of  the  crest  of 
the  ilium  are  two  prominences  (the  anterior  and  posterior  spinous 
processes)  which  are  points  from  which  certain  measurements  are 
sometimes  taken.  The  internal  surface  of  the  upper  fan-shaped 
portion  of  the  os  innominatum  gives  attachment  to  the  iliacus  muscle, 
and  contributes  to  the  support  of  the  abdominal  contents ;  along  with 
its  fellow  of  the  opposite  side  it  forms  the  false  pelvis.  The  false  is 
separated  from  the  true  pelvis  by  the  ilio-pectineal  line,  which,  with 
the  upper  margin  of  the  sacrum,  forms  the  brim  of  the  pelvis.  This 
is  of  especial  obstetric  importance,  as  it  is  the  first  part  of  the  pelvic 
cavity  through  which  the  child  passes,  and  that  in  which  osseous 
deformities  are  most  often  met  with.  At  one  portion  of  the  ilio- 
pectineal  line,  corresponding  with  the  junction  of  the  ilium  and  pubes, 
is  situated  a  prominence,  which  is  known  as  the  ilio-pectineal  eminence. 

Internal  Surface. — The  internal  smooth  surface  of  the  innominate 
bone  below  the  linea  ilio-pectinea  forms  the  greater  portion  of  the 
pelvis  proper.  In  front,,  with  the  corresponding  portions  of  the 
opposite  bone,  it  forms  the  arch  of  the  pubes,  under  which  the  head 
of  the  child  passes  in  labor. 

Behind  this  we  observe  the  oval  obturator  foramen,  and  below  that 
the  tuberosity  and  spine  of  the  ischium,  the  latter  separating  the  great 
and  lesser  sciatic  notches,  and  giving  attachment  to  ligaments  of  im- 
portance. The  rough  articulating  surface  posteriorly,  by  which  the 
junction  with  the  sacrum  is  effected,  may  be  noted,  and  above  this 


ANATOMY    OF    THE    PELVIS.  27 

the  prominence  to  which  the  powerful  ligaments  joining  the  sacrum 
and  os  innominatum  are  attached. 

The  sacrum  (Fig.  2)  is  a  triangular  and  somewhat  spongy  bone, 
forming  the  continuation  of  the  spinal  column,  and  binding  together 
the  ossa  innominata.  It  is  originally 
composed  of  five  separate  portions,  anal- 
ogous to  the  vertebrae,  which  ossify  and 
unite  about  the  period  of  puberty,  leaving 
on  its  internal  surface  four  prominent 
ridges  at  the  points  of  junction.  The 
upper  of  these  is  sometimes  so  well 
marked  as  to  be  mistaken,  on  vaginal 
examination,  for  the  promontory  of  the 
sacrum  itself. 

The  base  of  the  sacrum  is  about  4J 
inches  in  width,  and  its  sides  rapidly  ap- 
proximate until  they  nearly  meet  at  its 
apex,  giving  the  whole  bone  a  triangular 
or  wedge  shape.  The  anterior  and  pos- 
terior surfaces  also  approximate  in  the 
same  way,  so  that  the  bone  is  much 
thicker  at  the  base  than  at  the  apex. 

.  •    •  rf   i  Sacrum  and  Coccyx. 

The  sacrum,  in  the  erect  position  of  the 

body,  is  directed  from  above  downwards  and  from  before  backwards. 
At  its  upper  edge  it  is  joined,  the  lumbo-sacral  cartilage  intervening, 
with  the  fifth  lumbar  vertebra.  The  point  of  junction,  called  the 
promontory  of  the  sacrum,  is  of  great  importance,  as  on  its  undue 
projection  many  deformities  of  the  brim  of  the  pelvis  depend.  The 
anterior  surface  of  the  bone  is  concave,  and  forms  the  curve  of  the 
sacrum ;  more  marked  in  some  cases  than  in  others.  There  is  also 
more  or  less  concavity  from  side  to  side.  On  it  we  observe  four 
apertures  on  each  side,  the  intervertebral  foramina,  giving  exit  to 
nerves.  The  posterior  surface  is  convex,  rough  and  irregular  for  the 
attachment  of  ligaments  and  muscles,  and  showing  a  ridge  of  vertical 
prominences,  corresponding  to  the  spinous  processes  of  the  vertebras. 
Mechanical  Relations  of  the  Sacrum. — The  sacrum  is  generally  de- 
scribed as  forming  a  keystone  to  the  arch  constituted  by  the  pelvic 
bones,  and  transmitting  the  weight  of  the  body,  in  consequence  of  its 
wedge-like  shape,  in  a  direction  which  tends  to  thrust  it  downwards 
and  backwards,  as  if  separating  the  ossa  innominata.  Dr.  Duncan,1 
however,  has  shown,  from  a  very  careful  consideration  of  its 
mechanical  relations,  that  it  should  rather  be  regarded  as  a  strong 
transverse  beam,  curved  on  its  anterior  surface,  the  extremities  of 
which  are  in  contact  with  the  corresponding  articular  surfaces  of  the 
ossa  innominata.  The  weight  of  the  body  is  thus  transmitted  to  the 
innominate  bones,  and  through  them  to  the  acetabula  and  the  femurs. 
(Fig.  3.)  There  counter-pressure  is  applied,  and  the  result  is,  as  we 
shall  subsequently  see,  an  important  modifying  influence  on  the 
development  and  shape  of  the  pelvis. 

1  Researches  in  Obstetrics,  p.  67. 


28  ORGANS    CONCERNED    IN    PARTURITION. 

The  coccyx  (Fig.  2)  is  composed  of  four  small  separate  bones,  which 
eventually  unite  into  one,  but  not  until  late  in  life.  The  uppermost 
of  these  articulates  with  the  apex  of  the  sacrum.  On  its  posterior 
surface  are  two  small  cornua,  which  unite  with  corresponding  points 
at  the  tip  of  the  sacrum.  The  bones  of  the  coccyx  taper  to  a  point. 
To  it  are  attached  various  muscles  which  have  the  eft'ect  of  imparting 
considerable  mobility.  During  labor,  also,  it  yields  to  the  mechanical 
pressure  of  the  presenting  part,  so  as  to  increase  the  antero- posterior 
diameter  of  the  pelvic  outlet  to  the  extent  of  an  inch  or  more. 

Ossification  of  Coccyx. — If,  through  disease  or  accident,  as  sometimes 
happens,  the  articular  cartilages  of  the  coccyx  become  prematurely 
ossified,  the  enlargement  of  the  pelvic  outlet  during  labor  may  be 
prevented,  and  considerable  difficulty  may  thus  arise.  This  is  most 
apt  to  happen  in  aged  prirniparae,  or  in  women  who  have  followed 
sedentary  occupations;  and  not  infrequently,  under  such  circum- 
stances, the  bone  fractures  under  the  pressure  to  which  it  is  subjected 
by  the  presenting  part. 

Pelvic  Articulations. — The  pelvic  bones  are  firmly  joined  together 
by  various  articulations  and  ligaments.  The  latter  are  arranged  so 
as  to  complete  the  canal  through  which  the  foetus  has  to  pass,  and 
which  is  in  great  part  formed  by  the  bones.  On  its  internal  surface, 
where  the  absence  of  obstruction  is  of  importance,  they  are  every- 
where smooth ;  while  externally,  where  strength  is  the  desideratum, 
they  are  arranged  in  larger  masses,  so  as  to  unite  the  bones  firmly 
together.  The  pelvic  articulations  have  been  generally  described  as 
symphyses  or  amphiarthrodia,  a  term  which  is  properly  applied  to 
two  articulating  surfaces,  united  by  fibrous  tissue  in  such  a  way  as 
to  prevent  any  sliding  motion.  It  is  certain,  however,  that  this  is 
not  the  case  with  the  joints  of  the  female  pelvis  during  pregnancy 
and  parturition.  Lenoir  found  that  in  22  females,  between  the  ages 
of  18  and  35,  there  was  a  distinct  sliding  motion.  Therefore,  the 
pelvic  articulations  are,  strictly  speaking,  to  be  considered  examples 
of  the  class  of  joints  termed  arthrodia. 

Lumbo-sacral  Joint. — The  last  lumbar  vertebra  is  united  to  the 
sacrum  by  ligamentous  union  similar  to  that  which  joins  the  vertebrae 
to  each  other.  The  intervening  fibro-cartilage  forms  a  disk,  which 
is  thicker  in  front  than  behind,  and  this,  in  connection  with  a  similar 
peculiarity  of  the  fifth  lumbar  vertebra,  tends  to  increase  the  sloped 
position  of  the  sacrum,  and  the  angle  which  it  forms  with  the  verte- 
bral column.  It  constitutes  the  most  prominent  portion  of  the  pro- 
montory of  the  sacrum,  and  is  the  part  on  which  the  finger  generallv 
impinges  in  vaginal  examinations.  The  anterior  common  vertebral 
ligament  passes  over  the  surface  of  the  joints,  and  we  also  find  the 
ligamenta  sub-flava  and  the  inter-spinous  ligaments,  as  in  the  other 
vertebrae.  The  articular  processes  are  joined  together  by  a  fibrous 
capsule,  and  there  is  also  a  peculiar  ligament,  the  lumbo-sacral, 
extending  from  the  transverse  process  of  the  vertebra  on  each  side, 
and  attaching  itself  to  the  sides  of  the  sacrum  and  the  sacro-iliac 
synchondrosis. 

Ligaments  of  Coccyx. — The  sacrum  is  joined  to  the  .coccyx,  and,  in 


ANATOMY    OF    THE    PELVIS. 


29 


some  cases  at  least,  the  separate  bones  of  the  coccyx  to  each  other, 
by  small  cartilaginous  disks  like  that  connecting  the  sacrum  with 
the  last  lumbar  vertebra.  They  are  farther  united  by  anterior  and 
posterior  common  ligaments,  the  latter  being  much  the  thicker  and 
more  marked.  In  the  adult  female  a  synovial  membrane  is  found 
between  the  sacrum  and  coccyx,  and  it  is  supposed  that  this  is  formed 
under  the  influence  of  the  movements  of  the  bones  on  each  other. 

Sacro-iliac  Syncliondrosis. — The  opposing  articular  surfaces  of  the 
sacrum  and  ilium  are  each  covered  by  cartilages,  that  of  the  sacrum 
being  the  thickest.  These  are  firmly  united,  but,  in  the  female, 
according  to  Mr.  Wood.1  they  are  always  more  or  less  separated  by 
an  intervening  synovial  membrane.  Posterior  to  these  cartilaginous 
convex  surfaces  there  are  strong  interosseous  ligaments,  passing 
directly  from  bone  to  bone,  filling  up  the  interspace  between  them, 
and  uniting  them  firmly.  There  are  also  accessory  ligaments,  such 
as  the  superior  and  anterior  sacro-iliac,  which  are  of  secondary  con- 
sequence. The  posterior  sacro-iliac  ligaments,  however,  are  of  great 
obstetric  importance.  They  are  the  very  strong  attachments  which 
unite  the  rough  surfaces  on  the  posterior  iliac  tuberosities  to  the 
posterior  and  lateral  surfaces  of  the  sacrum.  They  pass  obliquely 

FIG.  3. 


Section  of  Pelvis  and  Heads  of  Thigh-bones,  showing  the  Suspensory  Action  of  the  Sacro-iliac 
Ligaments.     (After  Wood.) 

downwards  from  the  former  points,  and  suspend,  as  it  were,  the 
sacrum  from  them.  According  to  Duncan,  the  sacrum  has  nothing 
to  prevent  its  being  depressed  by  the  weight  of  the  body  but  these 

1  Todd's  Cyclopaedia  of  Anatomy  and  Physiology,  article  "Pelvis,"  p.  123. 


30  ORGANS    CONCERNED    IN    PARTURITION. 

ligaments,  and  it  is  mainly  through  them  that  the  weight  of  the  body 
is  transmitted  to  the  sacro-cotyloid  beams  and  the  heads  of  the  femur. 

Sacro-sciatic  Liyaments. — The  sacro-sciatic  ligaments  are  instru- 
mental in  completing  the  canal  of  the  pelvis.  The  greater  sacro- 
sciatic  ligament  is  attached  by  a  broad  base  to  the  posterior  spine  of 
the  ilium,  and  to  the  posterior  surfaces  of  the  ilium  and  coccyx.  Its 
fibres  unite  into  a  thick  cord,  cross  each  other  in  an  X-like  manner, 
and  again  expand  at  their  insertion  into  the  tuberosity  of  the  ischium. 
The  lesser  sacro-sciatic  ligament  is  also  attached  with  the  former  to 
the  back  parts  of  the  sacrum  and  coccyx,  its  fibres  passing  to  their 
much  narrower  insertion  at  the  spine  of  the  ischium,  and  converting 
the  sacro-sciatic  notch  into  a  complete  foramen. 

Obturator  Membrane. — The  obturator  membrane  is  the  fibrous 
aponeurosis  that  closes  the  large  obturator  foramen.  Joulin1  supposes 
that,  along  with  the  sacro-sciatic  ligaments,  it  may,  by  yielding  some- 
what to  the  pressure  of  the  fcetal  head,  tend  to  prevent  the  contusion 
to  which  the  soft  parts  would  be  subjected  if  they  were  compressed 
bet  \veen  two  entirely  osseous  surfaces. 

Symphynt  Pubis. — The  junction  of  the  pubic  bones  in  front  is 
effected  by  means  of  two  oval  plates  of  fibro-cartilage,  attached  to 
each  articular  surface  by  nipple-shaped  projections,  which  fit  into 
corresponding  depressions  in  the  bones.  There  is  a  greater  separa- 
tion between  the  bones  in  front  than  behind,  where  the  numerous 
fibres  of  the  cartilaginous  plates  intersect,  and  unite  the  bones  firmly 
together.  At  the  upper  and  back  part  of  the  articulation  there  is 
an  interspace  between  the  cartilages,  which  is  lined  by  a  delicate 
membrane.  In  pregnancy  this  space  often  increases  in  size,  so  as 
to  extend  even  to  the  front  of  the 'joint.  The  juncture  is  further 
strengthened  by  four  ligaments,  the  anterior,  the  posterior,  the  supe- 
rior, and  the  sub-pubic.  Of  these,  the  last  is  the  largest,  connecting 
together  the  pubic  bones  and  forming  the  upper  boundary  of  the 
pubic  arch. 

Movements  of  Pelvic  Joints. — The  close  apposition  of  the  bones  of 
the  pelvis  might  not  unreasonably  lead  to  the  supposition  that  no 
movement  took  place  between  its  component  parts ;  and  this  is  the 
opinion  which  is  even  yet  held  by  many  anatomists.  It  is  tolerably 
certain,  however,  that  even  in  the  unimpregnated  condition  there  is 
a  certain  amount  of  mobility.  Thus  Zaglas  has  pointed  out2  that  in 
man  there  is  a  movement  in  an  antero-posterior  direction  of  the 
sacro-iliac  joints,  which  has  the  eifect,  in  certain  positions  of  the  body, 
of  causing  the  sacrum  to  project  downwards  to  the  extent  of  about 
a  line,  thus  narrowing  the  pelvic  brim,  tilting  up  the  point  of  the 
bone,  and  thereby  enlarging  the  outlet  of  the  pelvis.  This  movement 
seems  habitually  brought  into  play  in  the  act  of  straining  during 
defecation. 

Observations  in  the  Lower  Animals. — During  pregnancy  in  some  of 
the  lower  animals  there  is  a  very  marked  movement  of  the  pelvic 
articulations,  which  materially  facilitates  the  process  of  parturition. 

1  Trait6  d'Accouchements,  p.  11. 

2  Monthly  Journal  of  Med.  Science,  Sept.  1851. 


ANATOMY    OF    THE    PELVIS.  31 

This,  in  the  case  of  the  guinea-pig  and  cow,  has  been  specially  pointed 
out  by  Dr.  Matthews  Duncan.1  In  the  former,  during  labor,  the 
pelvic  bones  separate  from  each  other  to  the  extent  of  an  inch  or 
more.  In  the  latter  the  movements  are  different,  for  the  symphysis 
pubis  is  fixed  by  bony  anchylosis,  and  is  immovable;  but  the  sacro- 
iliac  joints  become  swollen  during  pregnancy,  and  extensive  move- 
ments in  an  antero-posterior  direction  take  place  in  them,  which 
materially  enlarge  the  pelvic  canal  during  labor. 

Mode  in  tohich  the  Movements  are  effected. — It  is  extremely  probable 
that  similar  movements  take  place  in  women,  both  in  the  symphysis 
pubis  and  in  the  sacro-iliac  joints,  although  to  a  less  marked  extent. 
These  are  particularly  well  described  by  Dr.  Duncan.  They  seem  to 
consist  chiefly  in  an  elevation  and  depression  of  the  symphysis  pubis, 
either  by  the  ilia  moving  on  the  sacrum,  or  by  the  sacrum  itself 
undergoing  a  forward  movement  on  an  imaginary  transverse  axis 
passing  through  it,  thus  lessening  the  pelvic  brim  to  the  extent  of 
one  or  even  two  lines,  and  increasing,  at  the  same  time,  the  diameter 
of  the  outlet  by  tilting  up  the  apex  of  the  sacrum.  These  movements 
are  only  an  exaggeration  of  those  which  Zaglas  describes  as  occurring 
normally  during  defecation.  The  instinctive  positions  which  the 
parturient  woman  assumes  find  an  explanation  in  these  observations. 
During  the  first  stage  of  labor,  when  the  head  is  passing  through  the 
brim,  she  sits,  or  stands,  or  walks  about,  and  in  these  erect  positions 
the  symphysis  pubis  is  depressed,  and  the  brim  of  the  pelvis  enlarged 
to  its  utmost.  As  the  head  advances  through  the  cavity  of  the 
pelvis,  she  can  no  longer  maintain  her  erect  position,  and  she  lies 
down  and  bends  her  body  forward,  which  has  the  effect  of  causing  a 
nutatory  motion  of  the  sacrum,  with  corresponding  tilting  up  of  its 
apex,  and  an  enlargement  of  the  outlet. 

Alterations  in  the  Pelvic  Joints  during  Pregnancy. — These  move- 
ments during  parturition  are  facilitated  by  the  changes  which  are 
known  to  take  place  in  the  pelvic  articulations  during  pregnancy. 
The  ligaments  and  cartilages  become  swollen  and  softened,  and  the 
synovial  membranes  existing  between  the  articulating  surfaces  become 
greatly  augmented  in  size  and  distended  with  fluid.  These  changes 
act  by  forcing  the  bones  apart,  as  the  swelling  of  a  sponge  placed 
between  them  might  do  after  it  had  imbibed  moisture.  The  reality 
of  these  alterations  receives  a  clinical  illustration  from  those  cases, 
which  are  far  from  uncommon,  in  which  these  changes  are  carried 
to  so  extreme  an  extent,  that  the  power  of  progression  is  materially 
interfered  with  for  a  considerable  time  after  delivery. 

Pelvis  as  a  Whole. — On  looking  at  a  pelvis  as  a  whole,  we  are  at 
once  struck  with  its  division  into  the  true  and  false  pelvis.  The 
latter  portion  (all  that  is  above  the  brim  of  the  pelvis)  is  of  compara- 
tively little  obstetric  importance,  except  in  giving  attachments  to 
the  accessory  muscles  of  parturition,  and  need  not  be  further  con- 
sidered. The  brim  of  the  pelvis  is  a  heart-shaped  opening,  bounded 
by  the  sacrum  behind,  the  linea  ilio-pectinea  on  either  side,  and  the 

1  Researches  in  Obstetrics,  p.  19. 


32 


ORGANS    CONCERNED    IN    PARTURITION. 


symphysis  of  the  pubes  in  front.  All  below  it  forms  the  cavity, 
which  is  bounded  by  the  hollow  of  the  sacrum  behind,  by  the  inner 
surfaces  of  the  innominate  bones  at  the  sides  and  in  front,  and  by  the 
posterior  surface  of  the  symphysis  pubis.  It  is  in  this  part  of  the 
pelvis  that  the  changes  in  direction  which  the  foetal  head  undergoes 


FIG.  4. 


Outlet  of  Pelvis. 

in  labor  are  imparted  to  it.  The  lower  border  of  this  canal,  or 
pelvic  outlet  (Fig.  4),  is  lozenge-shaped,  is  bounded  by  the  ischiatic 
tuberosities  on  either  side,  the  tip  of  the  coccyx  behind,  and  the 
under  surface  of  the  pubic  symphysis  in  front.  Posteriorly  to  the 
tuberosities  of  the  ischia  the  boundaries  of  the  outlet  are  completed 
by  the  sacro-sciatic  ligaments. 

Differences  in  the  two  Sexes. — There  is  a  very  marked  difference 
between  the  pelvis  in  the  male  and  the  female,  and  the  peculiarities 
of  the  latter  all  tend  to  facilitate  the  process  of  parturition.  In  the 
female  pelvis  (Fig.  5)  all  the  bones  are  lighter  in  structure,  and  have 

FIG.  5. 


The  Female  Pelvis. 


the  points  for  muscular  attachments  much  less  developed.     The  iliac 
bones  are  more  spread  out,  hence  the  greater  breadth  which  is  ob- 


ANATOMY    OF    THE    PELVIS.  33 

served  in  the  female  figure,  and  the  peculiar  side-to-side  movement 
which  all  females  have  in  walking.  The  tuberosities  of  the  ischia 
are  lighter  in  structure  and  further  apart,  and  the  rami  of  the  pubes 
also  converge  at  a  much  less  acute  angle.  This  greater  breadth  of 
the  pubic  arch  gives  one  of  the  most  easily  appreciable  points  of 

Fiu.  G. 


The  Male  Pelvis. 


contrast  between  the  male  and  female  pelvis;  the  pubic  arch  in  the 
female  forms  an  angle  of  from  90°  to  100°,  while  in  the  male  (Fig. 
6)  it  averages  from  70°  to  75°.  The  obturator  foramina  are  more 
triangular  in  shape. 

The  whole  cavity  of  the  female  pelvis  is  wider  and  less  funnel- 
shaped  than  in  the  male,  the  symphysis  pubis  is  not  so  deep,  and,  as 
the  promontory  of  the  sacrum  does  not  project  so  much,  the  shape 
of  the  pelvic  brim  is  more  oval  than  heart-shaped.  These  differences 
between  the  male  and  female  pelves  are  probably  due  to  the  presence 
of  the  female  genital  organs  in  the  true  pelvis,  the  growth  of  which 
increases  its  development  in  width.  In  proof  of  this,  Schroeder  states 
that  in  women  with  congenitally  defective  internal  organs,  and  in 
women  who  have  had  both  ovaries  removed  early  in  life,  the  pelvis 
has  always  more  or  less  of  the  masculine  type. 

Measurements  of  the  Pelvis. — The  measurements  of  the  pelvis  that 
are  of  most  importance  from  an  obstetric  point  of  view,  are  taken 
between  various  points  directly  opposite  to  each  other,  and  are  known 
as  the  diameters  of  the  pelvis.  Those  of  the  true  pelvis  are  the  dia- 
meters which  it  is  especially  important  to  fix  in  our  memories,  and 
it  is  customary  to  describe  three  in  works  on  obstetrics — the  antero- 
posterior  or  conjugate,  the  oblique,  and  the  transverse — although  of 
course  the  measurements  may  be  taken  at  any  opposing  points  in 
the  circumference  of  the  bones.  The  antero-posterior  (sacro- pubic), 
at  the  brim  (Fig.  7),  is  taken  from  the  upper  part  of  the  posterior 
surface  of  the  symphysis  pubis  to  the  centre  of  the  promontory  of  the 
sacrum;  in  the  cavity,  from  the  centre  of  the  symphysis  pubis  to  a 
corresponding  point  in  the  body  of  the  third  piece  of  the  sacrum;  and 


34 


ORGANS    CONCERNED    IN    PARTURITION 


Brim  of  Pelvis,  showing  Aniero-posterior,  Oblique,  and  Conjugate  Diameters. 


FIG.  8. 


Transverse  Section  of  Pelvis,  showing  the 
Diameters. 


at  the  outlet  (coccy-pubic),  from 
the  lower  border  of  the  symphysis 
pubis  to  the  tip  of  the  coccyx. 
The  oblique,  at  the  brim,  is  taken 
from  the  sacro-iliac  joint  on  either 
side  to  a  point  of  the  brim  corres- 
ponding with  the  ilio-pectineal  em- 
inence (that  starting  from  the  right 
sacro-iliac  joint  being  called  the 
right  oblique,  that  from  the  left,  the 
oblique);  in  the  cavity  a  similar 
measurement  is  made  at  the  same 
level  as  the  conjugate;  while  at 
the  outlet  an  oblique  diameter  is 
not  usually  measured.  The  trans- 
verse is  taken  at  the  brim,  from  a 
point  midway  between  the  sacro- 
iliac  joint  and  the  ilio-pectineal 
eminence  to  a  corresponding  point 
at  the  opposite  side  of  the  brim ; 
in  the  cavity  from  points  in  the 
same  plane  as  the  conjugate  and 
oblique  diameters;  and  at  the 
outlet  from  the  centre  of  the  inner 
border  of  one  ischial  tuberosity  to 
that  of  the  other.  The  measure- 
ments given  by  various  writers 
differ  considerably,  and  vary  some- 
what in  different  pelves.  Taking 
the  average  of  a  large  number, 
the  following  may  be  given  as  the 
standard  measurements  of  the 
female  pelvis: — 


ANATOMY    OF    THE    PELVIS.  3o 

Aiitero-posterior.  Oblique.  Transverse, 

in.  in.                         in. 

Brim 4.  25  4.S                  5.2 

Cavity       .....          4.7  5.2                  4.75 

Outlet 5.0  4.2 

It  will  be  observed  that  the  lengths  of  the  corresponding  dia- 
meters at  different  places  vary  greatly;  thus  while  the  transverse 
is  longest  at  the  brim,  the  oblique  is  longest  in  the  cavity,  and  the 
antero-posterior  at  the  outlet.  It  will  be  subsequently  seen  that 
this  fact  is  of  great  practical  importance  in  studying  the  mecha- 
nism of  delivery,  for  the  head  in  its  descent  through  the  pelvis  alters 
its  position  in  such  a  way  as  to  adapt  itself  to  the  largest  diameter 
of  the  pelvis;  thus  as  it  passes  through  the  cavity  it  lies  in  the 
oblique  diameter,  and  then  rotates  so  as  to  be  expelled  in  the  antero- 
posterior  diameter  of  the  outlet. 

Diameters  as  altered  by  Soft  Parts. — In  thinking  of  these  measure- 
ments of  the  pelvis,  it  must  not  be  forgotten  that  they  are  taken  in 
the  dried  bones,  and  that  they  are  considerably  modified  during  life 
by  the  soft  parts.  This  is  especially  the  case  at  the  brim,  where  the 
projection  of  the  psoas  and  iliacus  muscles  lessens  the  transverse 
diameter  about  half  an  inch,  while  the  antero-posterior  diameter  of 
the  brim,  and  all  the  diameters  of  the  cavity,  are  lessened  by  a 
quarter  of  an  inch.  The  right  oblique  diameter  of  the  brim  is,  even 
in  the  dried  pelvis,  found  to  be,  on  an  average,  slightly  longer  than 
the  left;  probably  on  account  of  the  increased  development  of  the 
right  side  of  the  pelvis  from  the  greater  use  made  of  the  right  leg; 
but  in  addition  to  this,  the  left  oblique  diameter  is  somewhat  lessened 
during  life  by  the  presence  of  the  rectum  on  the  left  side.  The 
advantage  gained  by  the  comparatively  frequent  passage  of  the  head 
through  the  pelvis  in  the  right  oblique  diameter  is  thus  explained. 

Other  Measurements. — There  are  one  or  two  other  measurements 
of  the  true  pelvis  which  are  sometimes  given,  but  which  are  of  secon- 
dary importance.  One  of  these,  the  sacro-cotyloid  diameter,  is  that 
between  the  promontory  of  the  sacrum  and  a  point  immediately 
above  the  cotyloid  cavity,  and  averages  from  3,-i  to  3.5  inches.  An- 
other, called  by  Wood  the  lower  or  inclined  conjugate  diameter,  is 
that  between  the  centre  of  the  lower  margin  of  the  symphysis  pubis 
and  the  promontory  of  the  sacrum,  and  averages  half  an  inch  more 
than  the  antero-posterior  diameter  of  the  brim.  These  measurements 
are  chiefly  of  importance  in  relation  to  certain  pelvic  deformities. 

External  Measurements. — The  external  measurements  of  the  pelvis 
are  of  no  real  consequence  in  normal  parturition,  but  they  may  help 
us,  in  certain  cases,  to  estimate  the  existence  and  amount  of  deformi- 
ties. Those  which  are  generally  given  are :  Between  the  anterior- 
superior  iliac  spines,  10  inches;  between  the  central  points  of  the 
crests  of  the  ilia,  10 J  inches;  between  the  spinous  process  of  the  last 
lumbar  vertebra  and  the  upper  part  of  the  symphysis  pubis  (external 
conjugate),  7  inches. 

Planes  of  the  Pelvis. — By  the  planes  of  the  pelvis  are  meant  imagi- 
nary levels  at  any  portion  of  its  circumference.  If  we  were  to  cut 


36 


ORGANS    CONCERNED    IN    PARTURITION. 


out  a  piece  of  cardboard  so  as  to  fit  the  pelvic  cavity,  and  place  it 
either  at  the  brim  or  elsewhere,  it  would  represent  the  pelvic  plane 
at  that  particular  part,  and  it  is  obvious  that  we  may  conceive  as 
many  planes  as  we  desire.  Observation  of  the  angle  which  the 
pelvic  planes  form  with  the  horizon  shows  the  great  obliquity  at 
which  the  pelvis  is  placed  in  regard  to  the  spinal  column.  Thus 
the  angle  A  B  I  (Fig.  9)  represents  the  inclination  to  the  horizon  of 

FIG.  9. 


Planes  of  the  Pelvis  with  Horizon. 

A  B.     Horizon.  c  D.     Vertical  line. 

A  u  i.     Angle  of  inclination  of  pelvis  to  horizon,  equal  to  6D°. 
B  i  c.     Angle  of  inclination  of  pelvis  to  spinal  column,  equal  to  150°. 
c  i  j.     Angle  of  inclination  of  sacrum  to  spinal  olumn,  equal  to  130°. 
K  F.     Axis  of  pelvic  inlet.  I.  M.     Mid  plane  in  the  middle  line. 

N.     Lowest  point  of  mid  plane  of  ischium. 

the  plane  of  the  pelvic  brim  I  B,  and  is  estimated  to  be  about  60°, 
while  the  angle  which  the  same  plane  forms  with  the  vertebral 
column  is  about  150°.  The  plane  of  the  outlet  forms,  with  the 
coccyx  in  its  usual  position,  an  angle  with  the  horizon  of  about  11°, 
but  which  varies  greatly  with  the  movements  of  the  tip  of  coccyx, 
and  the  degree  to  which  it  is  pushed  back  during  parturition.  These 
figures  must  only  be  taken  as  giving  an  approximative  idea  of  the 
inclination  of  the  pelvis  to  the  spinal  column,  and  it  must  be  remem- 
bered that  the  degree  of  inclination  varies  considerably  in  the  same 
female  at  different  times,  in  accordance  with  the  position  of  the  body. 
During  pregnancy  especially,  the  obliquity  of  the  brim  is  lessened  by 
the  patient  throwing  herself  backwards  in  order  to  support  more 
easily  the  weight  of  the  gravid  uterus.  The  height  of  the  promon- 
tory of  the  sacrum  above  the  upper  margin  of  the  symphysis  pubis 


ANATOMY    OF    THE    PELVIS. 


37 


is  on  an  .average  about  3f  inches,  and  a  line  passing  horizontally 
backwards  from  the  latter  point  would  impinge  on  the  junction  of 
the  second  and  the  third  coccygeal  bones. 

Axes  of  the  Parturient  Canal. — By  the  axis  of  the  pelvis  is  meant 
an  imaginary  line  which  indicates  the  direction  which  the  foetus 
takes  during  its  expulsion.  The  axis  of  the  brim  (Fig.  10)  is  a  line 

FKJ.  10. 


\D 


Axes  of  the  Pelvis. 

A.  Axis  of  superior  plane.  B.  Axis  of  mid  plane. 

D.  Axis  of  canal. 


c.  Axis  of  inferior  plane. 
E.  Horizon. 


drawn  perpendicular  to  its  plane,  which  would  extend  from  the  um- 
bilicus to  about  the  apex  of  the  coccyx ;  the  axis  of  the  outlet  of  the 
bony  pelvis  intersects  this,  and  extends  from  the  centre  of  the  pro- 
montory of  the  sacrum  to  midway  between  the  tuberosities  of  the 
ischia.  The  axis  of  the  entire  pelvic  canal  is  represented  by  the  sum 
of  the  axes  of  an  indefinite  number  of  planes  at  different  levels  of 
the  pelvic  cavity,  which  forms  an  irregular  parabolic  line,  as  repre- 
sented in  the  accompanying  diagram  (Fig.  10,  A  D). 

It  must  be  borne  in  mind,  however,  that  it  is  not  the  axis  of  the 
bony  pelvis  alone  that  is  of  importance  in  obstetrics.  We  must 
always,  in  considering  this  subject,  remember  that  the  general  axis 
of  the  parturient  canal  (Fig.  11)  also  includes  that  of  the  uterine 
cavity  above,  and  of  the  soft  parts  below.  These  are  variable  in 
direction  according  to  circumstances ;  and  it  is  only  the  axis  of  that 
portion  of  the  parturient  canal  extending  between  the  plane  of  the 
pelvic  brim  and  a  plane  between  the  lower  edge  of  the  pubic  sym- 
physis  and  the  base  of  the  coccyx  that  is  fixed.  The  axis  of  the 
lower  part  of  the  canal  will  vary  according  to  the  amount  of  disten- 
sion of  the  perineum  during  labor ;  but  when  this  is  stretched  to 
its  utmost,  just  before  the  expulsion  of  the  head,  the  axis  of  the  plane 


38 


ORGANS    CONCERNED    IN    PARTURITION 


between  the  edge  of  the  distended  perineum  and  the  lower  border  of 
the  syraphysis,  looks  nearly  directly  forwards.  The  axis  of  the  ute- 
rine cavity  generally  corresponds  with  that  of  the  pelvic  brim,  but 


FIG.  11. 


EC  presenting  General  Axis  of  Parturient  Canal,  including  the  Uterine  Cavity  and  Soft  Parts. 

it  may  be  much  altered  by  abnormal  positions  of  the  uterus,  such  as 
anteversion  from  laxity  of  the  abdominal  walls.  The  foetus,  under 
such  circumstances,  will  not  enter  the  brim  in  its  proper  axis,  and 
difficulties  in  the  labor  arise.  A  knowledge  of  the  general  direction 

of  the  parturient  canal  is  of  great 
FIG.  12.  importance    in  practical   midwifery 

in  guiding  us  to  the  introduction  of 
the  hand  or  instruments  in  obstetric 
operations,  and  in  showing  us  how 
to  obviate  difficulties  arising  from 
such  accidental  deviations  of  the 
uterus  as  have  been  just  alluded  to. 
Cavity  of  the  Pelvis.  —  The  ar- 
rangements of  the  bones  in  the  in- 
terior of  the  pelvic  canal  (Fig.  12) 
are  important  in  relation  to  the 
mechanism  of  delivery.  A  line 
passing  between  the  spine  of  the 
ischium  and  the  ilio-pectineal  emi- 
nence divides  the  inner  surface  of 
side  view  of  Peivig.  ischial  bone  into  two  smooth  plane 


ANATOMY    OF    THE    PELVIS.  39 

surfaces,  which  have  received  the  name  of  the  planes  of  the  ischium. 
Two  other  planes  are  formed  by  the  inner  surfaces  of  the  pubic 
bones  in  front  and  by  the  upper  portion  of  the  sacrum  behind, 
both  having  a  direction  downwards  and  backwards.  In  studving  the 
mechanism  of  delivery,  it  will  be  seen  that  many  obstetricians  at- 
tribute to  these  planes,  in  conjunction  with  the  spine  of  the  ischium, 
a  very  important  influence  in  effecting  rotation  of  the  foetal  head 
from  the  oblique  to  the  antero-posterior  diameter  of  the  pelvis. 

Development  of  the  Pelvis. — The  peculiarities  of  the  pelvis  during 
infancy  and  childhood  are  of  interest  as  leading  to  a  knowledge  of 
the  manner  in  which  the  form  observed  during  adult  life  is  impressed 
upon  it.  The  sacrum  in  the  pelvis  of  the  child  (Fig.  13)  is  less  de- 

FIG.  13. 


Pelvis  of  a  Child. 


yeloped  transversely,  and  is  much  less  deeply  curved  than  in  the 
adult.  The  pubes  is  also  much  shorter  from  side  to  side,  and  the 
pubic  arch  is  an  acute  angle.  The  result  of  this  narrowness  of  both 
the  pubes  and  sacrum  is  that  the  transverse  diameter  of  the  pelvic 
brim  is  shorter  instead  of  longer  than  the  antero-posterior.  The  sides 
of  the  pelvis  have  a  tendency  to  parallelism,  as  well  as  the  antero- 
posterior  walls ;  and  this  is  stated  by  Wood  to  be  a  peculiar  charac- 
teristic of  the  infantile  pelvis.  The  iliac  bones  are  not  spread  out  as 
in  adult  life,  so  that  the  centres  of  the  crests  of  the  ilium  are  not 
more  distant  from  each  other  than  the  anterior  superior  spines.  The 
cavity  of  the  true  pelvis  is  small,  the  tuberosities  of  the  ischia  are 
proportionately  nearer  to  each  other  than  they  afterwards  become ; 
the  pelvic  viscera  are  consequently  crowded  up  into  the  abdominal 
cavity,  which  is,  for  this  reason,  much  more  prominent  in  children 
than  in  adults.  The  bones  are  soft  and.  semi-cartilaginous  until  after 
the  period  of  puberty,  and  yield  readily  to  the  mechanical  influences 
to  which  they  are  subjected;  and  the  three  divisions  of  the  innomi- 
nate bone  remain  separate  until  about  the  twentieth  year. 

As  the  child  grows  older  the  transverse  development  of  the  sacrum 
increases,  and  the  pelvis  begins  to  assume  more  and  more  of  the  adult 


40  ORGANS    CONCERNED    IN    PARTURITION. 

shape.  The  mere  growth  of  the  bones,  however,  is  not  sufficient  to 
account  for  the  change  in  the  shape  of  the  pelvis,  and  it  has  been 
well  shown  by  Duncan  that  this  is  chiefly  produced  by  the  pressure 
to  which  the  bones  are  subjected  during  early  life.  The  iliac  bones 
are  acted  upon  by  two  principal  and  opposing  forces.  One  is  the 
weight  of  the  body  above,  which  acts  vertically  upon  the  sacral  ex- 
tremity of  the  iliac  beam  through  the  strong  posterior  sacro-iliac 
ligaments,  and  tends  to  throw  the  lower  or  acetabular  ends  of  the 
sacro-cotyloid  beams  outwards.  This  outward  displacement,  how- 
ever, is  resisted,  partly  by  the  junction  between  the  two  acetabular 
ends  at  the  front  of  the  pelvis,  but  chiefly  by  the  opposing  force, 
which  is  the  upward  pressure  of  the  lower  extremities  through  the 
femurs.  The  result  of  these  counteracting  forces  is  that  the  still 
soft  bones  bend  near  their  junction  with  the  sacrum ;  and  thus  the 
greater  transverse  development  of  the  pelvic  brim  characteristic  of 
adult  life  is  established.  In  treating  of  pelvic  deformities  it  will  be 
seen  that  the  same  forces  applied  to  diseased  and  softened  bone.<  ex- 
plain the  peculiarities  of  form  that  they  assume. 

Pelvis  in  Different  Races. — The  researches  that  have  been  made  on 
the  differences  of  the  pelvis  in  different  races  prove  that  these  are 
not  so  great  as  might  have  been  expected.  Joulin  pointed  out  that 
in  all  human  pelves  the  transverse  diameter  was  larger  than  the 
antero-posterior,  while  the  reverse  was  the  case  in  all  the  lower 
animals,  even  in  the  highest  simiae.  This  observation  has  been  more 
recently  confirmed  by  Von  Franque,1  who  has  made  careful  measure- 
ments of  the  pelvis  in  various  races.  In  the  pelvis  of  the  gorilla 
the  oval  form  of  the  brim,  resulting  from  the  increased  length  of  the 
conjugate  diameter,  was  very  marked.  In  certain  races  there  is  so 
far  a  tendency  to  aniraality  of  type,  that  the  difference  between  the 
transverse  and  conjugate  diameters  is  much  less  than  in  European 
women,  but  is  not  sufficiently  marked  to  enable  us  to  refer  any  given 
pelvis  to  a  particular  race.  Yon  Franque  makes  the  general  obser- 
vation that  the  size  of  the  pelvis  increases  from  South  to  North,  but 
that  the  conjugate  diameter  increases  in  proportion  to  the  transverse 
in  southern  races. 

Soft  Parts  in  Connection  icith  Pelvis. — In  closing  the  description  of 
the  pelvis,  the  attention  of  the  student  must  be  directed  to  the  mus- 
cular and  other  structures  \vhich  cover  it.  It  has  already  been 
pointed  out  that  the  measurements  of  the  pelvic  diameters  are  con- 
siderably lessened  by  the  soft  parts,  which  also  influence  parturition 
in  other  ways.  Thus  attached  to  the  crests  of  the  ilia  are  strong 
muscles  which  not  only  support  the  enlarged  uterus  during  pregnancy, 
but  are  powerful  accessory  muscles  in  labor :  in  the  pelvic  cavity  are 
the  obturator  and  pyriformis  muscles  lining  it  on  either  side ;  the 
pelvic  cellular  tissue  and  fasciae ;  the  rectum  and  bladder ;  the  vessels 
and  nerves,  pressure  on  which  often  gives  rise  to  cramps  and  pains 
during  pregnancy  and  labor ;  while  below  the  outlet  of  the  pelvis  is 
closed,  and  its  axis  directed  forwards,  by  the  numerous  muscles  form- 
ing the  floor  of  the  pelvis  and  perineum. 

1  Scanzoni's  Beitrage,  1867. 


THE  FEMALE  GENERATIVE  ORGANS.  41 


CHAPTER  II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function. — The  reproductive  organs  in  the 
female  are  conveniently  divided,  according  to  their  functions,  into : 
1,  The  external  or  copulative  organs,  which  are  chiefly  concerned  in 
the  act  of  insemination,  and  are  only  of  secondary  importance  in 
parturition:  they  include  all  the  organs  situated  externally  which 
form  the  vulva;  and  the  vagina,  which  is  placed  internally  and  forms 
the  canal  of  communication  between  the  uterus  and  the  vulva.  2, 
The  internal  or  formative  organs :  they  include  the  ovaries,  which 
are  the  most  important  of  all,  as  being  those  in  which  the  ovule  is 
formed;  the  Fallopian  tubes,  through  which  the  ovule  is  carried  to 
the  uterus ;  and  the  uterus,  in  which  the  impregnated  ovule  is  lodged 
and  developed. 

1.  The  external  organs  consist  of: — 

Mons  Veneris. — The  rnons  veneris,  a  cushion  of  adipose  and  fibrous 
tissue  which  forms  a  rounded  projection  at  the  upper  part  of  the 
vulva.  It  is  in  relation  above  with  the  lower  part  of  the  hypogastric 
region,  from  which  it  is  often  separated  by  a  furrow,  and  below  it  is 
continuous  with  the  labia  majora  on  either  side.  It  lies  over  the 
symphysis  and  horizontal  rami  of  the  pubes.  After  puberty  it  is 
covered  with  hair.  On  its  integument  are  found  the  openings  ot 
numerous  sweat  and  sebaceous  glands. 

Lalria  Majora. — The  labia  majora  form  two  symmetrical  sides  to 
the  longitudinal  aperture  of  the  vulva.  They  have  two  surfaces,  one 
external,  of  ordinary  integument,  covered  with  hair,  and  another 
internal,  of  smooth  mucous  membrane,  in  apposition  with  the  corre- 
sponding portion  of  the  opposite  labium,  and  separated  from  the 
external  surface  by  a  free  convex  border.  They  are  thicker  in  front, 
where  they  run  into  the  mons  veneris,  and  thinner  behind,  where 
they  are  united,  in  front  of  the  perineum,  by  a  thin  fold  of  integu- 
ment called  the  fourchette,  which  is  almost  invariably  ruptured  in 
the  first  labor.  In  the  virgin  the  labia  are  closely  in  apposition,  and 
conceal  the  rest  of  the  generative  organs.  After  child-bearing  they 
become  more  or  less  separated  from  each  other,  and  in  the  aged  they 
waste,  and  the  internal  nymphse  protrude  through  them.  Both  their 
cutaneous  and  mucous  surfaces  contain  a  large  number  of  sebaceous 
glands,  opening  either  directly  on  the  surface  or  into  the  hair  follicles. 
In  structure  the  labia  are  composed  of  connective  tissue,  containing 
a  varying  amount  of  fat,  and  parallel  with  their  external  surface  are 
placed  tolerably  close  plexuses  of  elastic  tissue,  interspersed  with 
regularly  arranged  smooth  muscular  fibres.  These  fibres  are  described 
by  Broca  as  forming  a  membranous  sac,  resembling  the  dartos  of  the 
4 


42  ORGANS    CONCERNED    IN    PARTURITION. 

scrotum,  to  which  the  labia  majora  are  analogous.  Towards  its  upper 
and  narrower  end  this  sac  is  continuous  with  the  external  inguinal 
ring,  and  in  it  terminate  some  of  the  fibres  of  the  round  ligament. 
The  analogy  with  the  scrotum  is  further  borne  out  by  the  occasional 
hernial  protrusion  of  the  ovary  into  the  labium,  corresponding  to  the 
normal  descent  of  the  testis  in  the  male. 

Labia  Minora. — The  labia  minora,  or  nymphae,  are  two  folds  of 
mucous  membrane,  commencing  below,  on  either  side,  about  the 
centre  of  the  internal  surface  of  the  labium  externum ;  they  converge 
as  they  proceed  upwards,  bifurcating  as  they  approach  each  other. 
The  lower  branch  of  this  bifurcation  is  attached  to  the  clitoris,  while 
the  upper  and  larger  unites  with  its  fellow  of  the  opposite  side,  and 
forms  a  fold  round  the  clitoris,  known  as  its  prepuce.  The  nymphae 
are  usually  entirely  concealed  by  the  labia  majora,  but  after  child- 
bearing  and  in  old  age  they  project  somewhat  beyond  them;  then 
they  lose  their  delicate  pink  color  and  soft  texture,  and  become  brown. 
dry,  and  like  skin  in  appearance.  This  is  especially  the  case  in  some 
of  the  negro  races,  in  whom  they  form  long  projecting  folds  called 
the  apron. 

The  surfaces  of  the  nymphae  are  covered  with  a  tesselated  epithe- 
lium, and  over  them  are  distributed  a  large  number  of  vascular 
papillae,  somewhat  enlarged  at  their  extremities,  and  sebaceous 
glands,  which  are  more  numerous  on  their  internal  surfaces.  The 
latter  secrete  an  odorous,  cheesy  matter,  which  lubricates  the  surface 
of  the  vulva,  and  prevents  its  folds  adhering  to  each  other.  The 
nymphae  are  composed  of  trabeculae  of  connective  tissue,  containing 
muscular  fibres. 

Clitoris. — The  clitoris  is  a  small  erectile  tubercle  situated  about 
half  an  inch  below  the  anterior  commissure  of  the  labia  majora.  It 
is  the  analogue  of  the  penis  in  the  male,  and  is  similar  to  it  in  struc- 
ture, consisting  of  a  corpus  cavernosum,  the  two  halves  of  which  are 
separated  by  a  fibrous  septum.  The  crura  are  covered  by  the  ischio- 
cavernous  muscles,  which  serve  the  same  purpose  as  in  the  male.  It 
has  also  a  suspensory  ligament.  The  corpora  caveruosa  are  composed 
of  a  vascular  plexus  with  numerous  traversing  muscular  fibres.  The 
arteries  are  derived  from  the  perineal  artery,  and  give  a  branch,  the 
cavernous,  to  each  half  of  the  organ;  there  is  also  a  dorsal  artery 
distributed  to  the  prepuce.  According  to  Gussenbauer  these  caver- 
nous arteries  pour  their  blood  directly  into  large  veins,  and  a  finer 
venous  plexus  near  the  surface  receives  arterial  blood  from  small 
arterial  branches.  By  these  arrangements  the  erection  of  the  organ 
which  takes  place  during  sexual  excitement  is  favored.  The  nervous 
supply  of  the  clitoris  is  large,  being  derived  from  the  internal  pudic 
nerve,  which  supplies  branches  to  the  corpora  cavernosa,  and  termi- 
nates in  the  glands  and  prepuce,  where  Paccinian  corpuscles  and  ter- 
minal bulbs  are  to  be  found.  On  this  account  the  clitoris  has  been 
supposed  by  some  to  be  the  chief  seat  of  voluptuous  sensation  in  the 
female. 

Vestibule . — The  vestibule  is  a  triangular  space,  bounded  at  its  apex 
by  the  clitoris,  and  on  either  side  by  the  folds  of  the  nymphae.  It  is 


THE  FEMALE  GENERATIVE  ORGANS.  43 

smooth,  and,  unlike  the  rest  of  the  vulva,  is  destitute  of  sebaceous 
glands,  although  there  are  several  groups  of  muciparous  glands  open- 
ing on  its  surface.  At  the  centre  of  the  base  of  the  triangle  which 
is  formed  by  the  upper  edge  of  the  opening  of  the  vagina,  is  a  promi- 
nence, distant  about  an  inch  from  the  clitoris,  on  which  is  the  orifice 
of  the  urethra.  This  prominence  can  be  readily  made  out  by  the 
finger,  and  the  depression  upon  it — leading  to  the  urethra — -is  of  im- 
portance as  our  guide  in  passing  the  female  catheter.  This  little 
operation  ought  to  be  performed  without  exposing  the  patient,  and 
it  is  done  in  several  ways.  The  easiest  is  to  place  the  tip  of  the 
index  finger  of  the  left  hand  (the  patient  lying  on  her  back)  on  the 
apex  of  the  vestibule,  and  slip  it  gently  down  until  we  feel  the  bulb 
of  the  urethra,  and  the  dimple  of  its  orifice,  which  is  generally  readily 
found.  If  there  is  any  difficulty  in  finding  the  orifice,  it  is  well  to 
remember  that  it  is  placed  immediately  below  the  sharp  edge  of  the 
lower  border  of  the  symphysis  pubis,  which  will  guide  us  to  it.  The 
catheter  (and  a  male  elastic  catheter  is  always  the  best,  especially 
during  labor,  when  the  urethra  is  apt  to  be  stretched)  is  then  passed 
under  the  thigh  of  the  patient,  and  directed  to  the  orifice  of  the 
urethra  by  the  finger  of  the  left  hand,  which  is  placed  upon  it.  We 
must  be  careful  that  the  instrument  is  really  passed  into  the  urethra, 
and  not  into  the  vagina.  It  is  advisable  to  have  a  few  feet  of  elastic 
tubing  attached  to  the  end  of  the  catheter,  so  that  the  urine  can  be 
passed  into  a  vessel  under  the  bed  without  uncovering  the  patient. 
If  the  patient  be  on  her  side,  in  the  usual  obstetric  position,  the  ope- 
ration can  be  more  readily  performed  by  placing  the  tip  of  the  finger 
in  the  vagina  and  feeling  its  upper  edge.  The  orifice  of  the  urethra 
lies  immediately  above  this,  and  if  the  catheter  be  slipped  along  the 
palmar  surface  of  the  finger,  it  can  generally  be  inserted  without 
much  trouble.  If,  however,  as  is  often  the  case  during  labor,  the 
parts  are  much  swollen,  it  may  be  difficult  to  find  the  aperture,  and 
it  is  then  always  better  to  look  for  the  opening  than  to  hurt  the 
patient  by  long-continued  efforts  to  feel  it.  [In  this  country,  the  in- 
strument is  almost  always  introduced  when  possible,  with  the  woman 
on  her  back. — ED.] 

Urethra. — The  urethra  is  a  canal  1 J  inches  in  length,  and  it  is  inti- 
mately connected  with  the  anterior  wall  of  the  vagina,  through  which 
it  may  be  felt.  It  is  composed  of  muscular  and  erectile  tissue,  and 
is  remarkable  for  its  extreme  dilatability,  a  property  which  is  turned 
to  practical  account  in  some  of  the  operations  for  stone  in  the  female 
bladder. 

Orifice  of  the  Vagina. — The  orifice  of  the  vagina  is  situated  imme- 
diately below  the  bulb  of  the  urethra.  In  virgins  it  is  a  circular 
opening,  but  in  women  who  have  borne  children  or  practised  sexual 
intercourse,  it  is,  in  the  undistended  state,  a  vertical  fissure.  In 
virgins  it  is  generally  more  or  less  blocked  up  by  a  fold  of  mucous 
membrane,  containing  some  cellular  tissue  and  muscular  fibres,  with 
vessels  and  nerves,  which  is  known  as  the  hymen.  This  is  most  often 
crescentic  in  shape,  with  the  concavity  of  the  crescent  looking  up- 


44  ORGANS    CONCERNED    IN    PARTURITION. 

wards ;  sometimes,  however,  it  is  circular  witli  a  central  opening,  or 
cribriform ;  or  it  may  even  be  entirely  imperforate,  and  this  gives 
rise  to  the  retention  of  the  menstrual  secretion.  These  varieties  of 
form  depend  on  the  peculiar  mode  of  development  of  the  fold  of 
vaginal  mucous  membrane  which  blocks  up  the  orifice  of  the  vagina 
in  the  foetus,  and  from  which  the  hymen  is  formed.  The  density  of 
the  membrane  also  varies  in  different  individuals.  Most  usually  it 
is  very  slight,  so  as  to  be  ruptured  in  the  first  sexual  approaches,  or 
even  by  some  accidental  circumstance,  such  as  stretching  the  limits, 
so  that  its  absence  cannot  be  taken  as  evidence  of  want  of  chastity. 
A  knowledge  of  this  fact  is  of  considerable  importance  from  a  medi- 
co-legal point  of  view.  Sometimes  it  is  so  tough  as  to  prevent  inter- 
course altogether,  and  may  require  division  by  the  knife  or  scissors 
before  this  can  be  effected ;  and  at  others  it  rather  unfolds  than  rup- 
tures, so  that  it  may  exist  even  after  impregnation  has  been  effected, 
and  it  has  been  met  with  intact  in  women  who  have  habitually  led 
unchaste  lives.  [It  may  also  form  an  obstacle  to  delivery,  and  re- 
quire to  be  incised  before  the  foetus  can  be  extruded. — ED.] 

Carunculse  Myrti formes. — The  carunculas  myrtiformes  are  small 
fleshy  tubercles,  varying  from  two  to  five  in  number,  situated  round 
the  orifice  of  the  vagina,  and  which  are  supposed  to  be  formed  by 
the  remains  of  the  ruptured  hymen. 

Vulvo-vayinal  Glands. — Near  the  posterior  part  of  the  vaginal 
orifice,  and  below  the  superficial  perinea!  fascia,  are  situated  t\\o 
conglomerate  glands  which  are  the  analogues  of  Cowper's  glands  in 
the  male.  Each  of  these  is  about  the  size  and  shape  of  an  almond, 
and  is  contained  in  a  cellular  fibrous  envelope.  Internally  they  are 
of  a  yellowish- white  color,  and  are  composed  of  a  number  of  lobules 
separated  from  each  other  by  prolongations  of  the  external  envelope. 
These  give  origin  to  separate  ducts  which  unite  into  a  common  canal, 
about  half  an  inch  in  length,  which  opens  in  front  of  the  attached 
edge  of  the  hymen  in  virgins,  and  in  married  women  at  the  base  of 
one  of  the  carunculas  myrtiformes.  According  to  Huguier,  the  size  of 
the  glands  varies  much  in  different  women,  and  they  appear  to  have 
some  connection  with  the  ovary,  as  he  has  always  found  the  largest 
gland  to  be  on  the  same  side  as  the  largest  ovary.  They  secrete  a 
glairy,  tenacious  fluid,  which  is  ejected  in  jets  during  the  sexual 
orgasm,  probably  through  the  spasmodic  action  of  the  perineal  mus- 
cles. At  other  times  their  secretion  serves  the  purpose  of  lubri- 
cating the  vulva,  and  thus  preserves  the  sensibility  of  its  mucous 
membrane. 

Fossa  Navicularis. — Immediately  behind  the  hymen  in  the  un- 
married, and  between  it  and  the  perineum,  is  a  small  depression 
called  the  fossa  navicularis,  which  disappears  after  childbearing. 

Perineum. — The  perineum  separates  the  orifice  of  the  vagina  from 
that  of  the  rectum.  It  is  about  1|  inches  in  breadth,  and  is  of  great 
obstetric  interest,  not  only  as  supporting  the  internal  organs  from 
below,  but  because  of  its  action  in  labor.  It  is  largely  stretched  and 
distended  by  the  presenting  part  of  the  child;  and  if  unusually  tough 


THE    FEMALE    GENERATIVE    OllGAXS. 


45 


and  unyielding  may  retard  delivery,  or  it  may  be  torn  to  a  greater 
or  less  extent,  thus  giving  rise  to  various  subsequent  troubles. 

Vascular  Supply  of  the  Vulva. — -The  structures  described  above 
together  form  the  vulva,  and  they  are  remarkable  for  their  abundant 
vascular  and  nervous  supply.  The  former  constitutes  an  erectile 
tissue  similar  to  that  which  has  already  been  described  in  the  cli- 
toris, and  which  is  especially  marked  about  the  bulb  of  the  vestibule 
(Fig.  14).  From  this  point,  and  extending  on  either  side  of  the 

FIG.  14. 


Vascular  Supply  of  Vulva.     (After  Kobelt. 


a.  Bulb  of  vestibule,    b.  Muscular  tissue  of  vagina,     c,  d,  e.,f.  The  clitoris  and  its  muscles,    g,  h, 
i,  1;  I,  nt,  n.  Veins  of  the  nymphse  and  clitoris  communicating  with  the  epigastric  and  obturator  veins. 

vagina,  there  is  a  well-marked  plexus  of  convoluted  veins,  which,  in 
their  distended  state,  are  likened  by  Dr.  Arthur  Farre  to  a  filled 
leech.  The  erection  of  the  erectile  tissue,  as  well  as  that  of  the 
clitoris,  is  brought  about  under  excitement,  as  in  the  male,  by  the 
compression  of  the  efferent  veins  by  the  contraction  of  the  ischio- 
cavernous  muscles,  and  by  that  of  a  thin  layer  of  muscular  tissues 
surrounding  the  orifice  of  the  vagina,  and  described  as  the  constrictor 
vaginae. 

Vagina. — The  vagina  is  the  canal  which  forms  the  communication 
between  the  external  and  internal  generative  organs,  through  which 
the  semen  passes  to  reach  the  uterus,  the  menses  flow,  and  the  foetus 
is  expelled.  Koughly  speaking,  it  lies  in  the  axis  of  the  pelvis,  but 
its  opening  is  placed  anterior  to  the  axis  of  the  pelvic  outlet,  so  that 
its  lower  portion  is  curved  forwards.  It  is  narrow  below,  but  dilated 
above,  where  the  cervix  uteri  is  inserted  into  it,  so  that  it  is  more  or 


46 


ORGANS    CONCERNED    IN    PARTURITION. 


less  conoidal  in  shape.  Generally  speaking,  its  anterior  and  posterior 
walls  lie  closely  in  contact,  but  they  are  capable  of  very  wide  dis- 
tension, as  during  the  passage  of  the  foetus.  The  anterior  wall  of 
the  vagina  is  shorter  than  the  posterior,  the  former  measuring  on  an 
average  2J  inches,  the  latter  3  inches;  but  the  length  of  the  canal 
varies  greatly  in  different  subjects  and  under  certain  circumstances. 
In  front  the  vagina  is  closely  connected  with  the  base  of  the  bladder, 
so  that  when  the  vagina  is  prolapsed,  as  often  occurs,  it  drags  the 
bladder  with  it  (Fig.  15);  behind,  it  is  in  relation  with  the  rectum, 

FIG.  15. 


Longitudinal  Section,  of  Body,  showing  Relations  of  Generative  Organs. 

but  less  intimately;  laterally  with  the  broad  ligaments  and  pelvic 
fascia:  and  superiorly  with  the  lower  portion  of  the  uterus  and  folds 
of  peritoneum  both  before  and  behind.  Th-e  Vagina  is  composed  of 
mucous,  muscular,  and  cellular  coats.  The  mucous  lining  is  thrown 
into  numerous  folds.  These  start  from  longitudinal  ridges  which 
exist  on  both  the  anterior  and  posterior  walls,  but  most  distinctly  on 
the  anterior.  They  are  very  numerous  in  the  young  and  unmarried, 
and  greatly  increase  the  sensitive  surface  of  the  vagina.  After  child- 
bearing,  and 'in  the  aged,  they  become  atrophied,  but  they  never 
completely  disappear,  and  towards  the  orifice  of  the  vagina,  where 
they  exist  in  greatest  abundance,  they  are  always  to  be  met  with. 
The  whole  of  the  mucous  membrane  is  lined  with  tesselated  epithe- 
lium, and  it  is  covered  with  a  large  number  of  papillae  either  conical 
or  divided,  which  are  highly  vascular  and  project  into  the  epithelial 


THE  FEMALE  GENERATIVE  ORGANS.  47 

layer.  Unlike  the  vulvar  mucous  membrane,  that  of  the  vagina 
seems  to  be  destitute  of  glands.  Beneath  the  epithelial  layer  is  a 
submueous  tissue  containing  a  large  number  of  elastic  and  some 
muscular  fibres,  derived  from  the  muscular  walls  of  the  vagina.  These 
are  strong  and  well-developed,  especially  towards  the  ostium  vagime. 
They  consist  of  two  layers — an  internal  longitudinal,  and  an  external 
circular — with  oblique  decussating  fibres  connecting  the  two.  Below 
they  are  attached  to  the  ischio-pubic  rami,  and  above  they  are  con- 
tinuous with  the  muscular  coat  of  the  uterus.  The  muscular  tissue 
of  the  vagina  increases  in  thickness  during  pregnancy,  but  to  a  much 
less  degree  than  that  of  the  uterus.  Its  vascular  arrangements,  like 
those  of  the  vulva,  are  such  as  to  constitute  an  erectile  tissue.  The 
arteries  form  an  intricate  network  around  the  tube,  and  eventually 
end  in  a  submueous  capillary  plexus,  from  which  twigs  pass  to  supply 
the  papiilas;  these  again  give  origin  to  venous  radicles  which  unite 
into  meshes  freely  interlacing  with  each  other,  and  forming  a  well- 
marked  venous  plexus. 

Internal  Organs  of  Generation.— -2.  The  internal  organs  of  gene- 
ration consist  of  the  uterus,  the  Fallopian  tubes,  and  the  ovaries ; 
and  in  connection  with  them  we  have  to  study  the  various  ligaments 
and  folds  of  peritoneum  which  serve  to  maintain  the  organs  in  posi- 
tion, along  with  certain  accessory  structures.  Physiologically,  the 
most  important  of  "all  the  generative  organs  are  the  ovaries,  in  which 
the  ovules  are  formed,  and  which  dominate  the  entire  reproductive 
life  of  the  female.  The  Fallopian  tubes  which  convey  the  ovule  to 
the  uterus,  and  fche  uterus  itself — whose^  main  function  is  to  receive, 
nourish,  and  eventually  expel  the  impregnated  product  of  the  ovary — 
may  be  said  to  be,  in  fact,  accessory  to  these  viscera.  Practically, 
however,  as  obstetricians,  we.  are  chiefly  concerned  with  the  uterus, 
and"  may  conveniently  commence  with  its  description. 

Uterus. — The  uterus  is  correctly  described  as  a  pyriform  organ, 
flattened  front  before  backwards,  consisting  of  the  body,  with  its 
rounded  fundus,  and  the  cervix  which  projects  into  the  upper  part 
of  the  vaginal  canal.  In  the  adult  female  it  is  deeply  situated  in 
the  pelvis,  being  placed  between  the  bladder  in  front  and  the  rectum 
behind,  its  fundus  being  below  the  plane  of  the  pelvic  brim  (Fig.  16). 
It  only  assumes  this  position,  however,  towards  the  period  of  puberty ; 
and  in  the  foetus  it  is  placed  much  higher,  and  lies,  indeed,  entirely 
within  the  cavity  of  the  abdomen.  It  is  maintained  in  this  position 
partly  by  being  slung  by  its  ligaments,  which  we  shall  subsequently 
study,  and  partly  by  being  supported  from  below  by  the  pelvic  cel- 
lular tissue  and  the  fleshy  column  of  the  vagina.  The  result  is  that 
the  uterus,  in  the  healthy  iemale,  is  a  perfectly  movable  body,  alter- 
ing its  position  to  suit 'the  condition  of  the  surrounding  viscera, 
especially  the  bladder  and  rectum,  which  are  subjected  to  variations 
of  size  according  to  their  fulness  or  emptiness.  When  from  any 
cause — as,  for  example,  some  peri-uterine  inflammation  producing 
adhesions  to  the  surrounding  textures^the  mobility  of  the  organ  is 
interfered  with,  much  distress  ensues,  and  if  pregnancy  supervenes 
more  or  less  serious  consequences  may  result.  Generally  speaking, 


48 


ORGANS    CONCERNED    IN    PARTURITION. 


the  uterus  may  be  said  to  lie  in  a  line  roughly  corresponding  with 
the  axis  of  the  pelvic  brim,  its  fundus  being  pointed  forwards  and 
its  cervix  lying  in  such  a  direction  that  a  line  drawn  from  it  would 
impinge  on  the  junction  between  the  sacrum  and  coccyx.  According 


FIG.  16. 


Transverse  Section  of  the  Body,  showing  Relations  of  the  Fnndus  Uteri. 

m.  Pubes.  a,  n  (in  front),  Remainder  of  hypogastric  arteries,  a,  a  (behind),  Spermatic  vessels 
and  nerves.  B.  Bladder.  L,  L.  Round  ligaments.  U.  Fundus  uteri,  t,  t.  Fallopian  tubes.  r>,  <>. 
Ovaries,  r.  Rectum,  g.  Right  ureter,  resting  on  the  psoas  muscle,  c.  Utero-sacral  ligaments,  v 
Last  lumbar  vertebra. 

to  some  authorities,  the  uterus  in  early  life  is  more  curved  in  the 
anterior  direction,  and  is,  in  fact,  normally  in  a  state  of  ante-flexion. 
Sappey  holds  that  this  is  not  necessarily  the  case,  but  that  the  amount 
of  anterior  curvature  depends  on  the  emptiness  or  fulness  of  the 
bladder,  on  which  the  uterus,  as  it  were,  moulds  itself  in  the  unim- 
pregnated  state.  It  is  believed  also  that  the  body  of  the  uterus  is 
very  generally  twisted  somewhat  obliquely,  so  that  its  anterior  sur- 
face looks  a  little  towards  the  right  side,  this  probably  depending  on 
the  presence  and  frequent  distension  of  the  rectum  in  the  left  side  of 
the  pelvis.  The  anterior  surface  of  the  uterus  is  convex,  and  is 
covered  in  three-fourths  of  its  extent  by  the  peritoneum,  which  is 
intimately  adherent  to  it.  Below  the  reflection  of  that  membrane  it 
is  loosely  connected  by  cellular  tissue  to  the  bladder,  so  that  any 
downward  displacement  of  the  uterus  drags  the  bladder  along  with  it. 
The  posterior  surface  is  also  convex,  but  more  distinctly  so  than  the 
anterior,  as  may  be  observed  in  looking  at  a  transverse  section  of 
the  organ  (Fig.  17).  It  is  also  covered  by  peritoneum,  the  reflection 
of  which  on  the  rectum  forms  the  cavity  known  as  Douglas's  pouch. 
The  fundus  is  the  upper  extremity  of  the  uterus,  lying  above  the 


THE  FEMALE  GENERATIVE  OUGAXS. 


49 


points  of  entry  of  tlie  Fallopian  tubes.  It  is  only  slightly  rounded 
in  the  virgin,  but  b°comes  more  decidedly  and  permanently  rounded 
in  the  woman  who  has  borne  children. 


FIG.  17. 


Transverse  Section  of  Uterus. 

Dimensions. — Until  the  period  of  puberty  the  uterus  remains  small 
and  undeveloped  (Fig.  18) ;  after  that  time  it  reaches  the  adult  size, 
at  which  it  remains  until  menstruation  ceases,  when  it  again  atrophies. 
If  the  woman  has  borne  children,  it  always  remains  larger  than  in 
the  nullipara.  In  the  virgin  adult  the  uterus  measures  2J  inches 
from  the  orifice  to  the  fundus,  rather  more  than  half  being  taken  up 

FIG.  18. 


Uterus  and  Appendages  in  an  Infant.     (After  Farre.) 

by  the  cervix.  Its  greatest  breadth  is  opposite  the  insertion  of  the 
Fallopian  tubes ;  its  greatest  thickness,  about  11  or  12  lines,  oppo- 
site the  centre  of  its  body.  Its  average  weight  is  about  9  or  10 
drachms.  Independently  of  pregnancy,  the  uterus  is  subject  to  great 
alterations  of  size  towards  the  menstrual  period,  when  on  account  of 
the  congestion  then  present,  it  enlarges,  sometimes,  it  is  said,  con- 
siderably. This  fact  should  be  borne  in  rnind,  as  this  periodical 
swelling  might  be  taken  for  an  early  pregnancy. 


50  ORGANS    CONCERNED    IN    PARTURITION. 

Regional  Divisions. — For  the  purpose  of  description  the  uterus  is 
conveniently  divided  into  the  fundns,  with  its  rounded  upper  ex- 
tremity, situated  between  the  insertions  at  the  Fallopian  tubes;  the 
body,  which  is  bounded  above  by  the  insertion  of  the  Fallopian  tubes, 
and  below  by  the  upper  extremity  of  the  cervix,  and  which  is  the 
part  chiefly  concerned  in  the  reception  and  growth  of  the  ovum;-  and 
the  cervix,  which  projects  into  the  vagyia,  and  dilates  during  labor 
to  give  passage  to  the  child.  The  cervix  is  conical  in  shape,  measur- 
ing 11  to  12  lines  transversely  at  the  base,  and  6  or  7  in  the  antero- 
posterior  direction ;  while  at  the  apex  it  measures  7  to  8  transversely, 
and  5  antero-posteriorly.  It  projects  about  4  lines  into  the  canal  of 
the  vagina,  the  remainder  of  the  cervix  being  placed  above  the 
reflection  of  the  vaginal  mucous  membrane.  It  varies  much  in  form 
in  the  virgin  and  nulliparous  married  woman,  and  in  the  woman 
who  has  borne  children;  and  the  differences  are  of  importance  in 
the  diagnosis  of  pregnancy  and  uterine  disease.  In  the  virgin  it  is 
regularly  pyramidal  in  shape.  At  its  lower  extremity  is  the  opening 
of  the  external  os  uteri,  forming  a  small  transverse  fissure,  sometimes 
difficult  to  feel,  and  generally  described  as  giving  a  sensation  to  the 
examining  finger  like  the  extremity  of  the  cartilage  at  the  tip  of  the 
nose.  It  is  bounded  by  two  lips,  the  anterior  of  which  is  apparently 
larger  on  account  of  the  position  of  the  uterus.  The  surface  of  the 
cervix,  and  the  borders  of  the  os,  are  very  smooth  and  regular. 

Changes  after  Childbirth. — In  women  who  have  borne  children 
these  parts  become  considerably  altered.  The  cervix  is  no  longer 
conical,  but  is  irregular  in  form  and  shortened.  The  lips  of  the  os 
uteri  become  fissured  and  lobulated,  on  account  of  partial  lacerations 
which  have  occurred  during  labor.  The  os  is  larger  and  more  irregu- 
lar in  outline,  and  is  sometimes  sufficiently  patulous  to  admit  the  tip 
of  the  finger.  In  old  age  the  cervix  atrophies,  and  after  the  change 
of  life  it  not  uncommonly  entirely  disappears,  so  that  the  orifice  of 
the  os  uteri  is  on  a  level  with  the  roof  of  the  vagina. 

Internal  Surface  of  the  Uterus. — The  internal  surface  of  the  uterus 
comprises  the  cavities  of  the  body  and  cervix — the  former  being 
rather  less  than  the  latter  in  length  in  virgins,  but  about  equal  in 
women  who  have  borne  children — separated  from  each  other  by 
a  constriction  forming  the  upper  boundary  of  the  cervical  canal. 
The  cavity  of  the  body  is  triangular  in  shape,  the  base  of  the  triangle 
being  formed  by  a  line  joining  the  openings  of  the  Fallopian  tubes, 
its  apex  by  the  upper  orifice  of  the  cervix,  or  internal  os,  as  it  is 
sometimes  called.  In  the  virgin  its  boundaries  are  somewhat  convex, 
projecting  inwards.  After  childbearing  they  become  straight  or 
slightly  concave.  The  opposing  surfaces  of  the  cavity  are  always  in 
contact  in  the  healthy  state,  or  are  only  separated  from  each  other 
by  a  small  quantity  of  mucus. 

Cavity  of  the  Cervix. — The  cavity  of  the  cervix  is  spindle-shaped 
or  fusiform,  narrower  above  and  below,  at  the  internal  and  external 
os  uteri,  and  somewhat  dilated  between  these  two  points.  It  is  flat- 
tened from  before  backwards,  and  its  opposing  surfaces  also  lie  in 
contact,  but  not  so  closely  as  those  of  the  body.  On  the  mucous 


THE  FEMALE  GENERATIVE  ORGANS. 


51 


lining  of  the  anterior  and  posterior  surfaces  is  a  prominent  perpen- 
dicular ridge,  with  a  lesser  one  at  each  side,  from  which  transverse 
ridges  proceed  at  more  or  less  acute  angles.  These  have  received 
the  name  of  the  arbor  vitse.  According  to  Guyon  the  perpendicular 
ridges  are  not  exactly  opposite,  so  that  they  fit  into  each  other,  and 
serve  more  completely  to  fill  up  the  cavity  of  the  cervix,  especially 
towards  the  internal  os  (Fig.  19).  The  arbor  vitre  is  most  distinct 
in  the  virgin,  and  atrophies  considerably  after  childbearing. 

FIG.  19. 


Portion  of  Interior  of  Cervix.     (Enlarged  nine  diameters.)     (After  Tyler  Smith  and  Hassall.) 

The  superior  extremity  of  the  cervical  canal  forms  a  narrow 
isthmus  separating  it  from  the  cavity  of  the  body,  and  measuring 
about  |ths  of  an  inch  in  diameter.  Like  the  external  os,  it  contracts 
after  the  cessation  of  menstruation,  and  in  old  age  sometimes  be- 
comes entirely  obliterated. 

Structure  of  the  Uterus. — The  uterus  is  composed  of  three  principal 
structures — the  peritoneal,  muscular,  and  mucous  coats.  The  peri- 
toneum forms  an  investment  to  the  greater  part  of  the  organ,  ex- 
tending downwards  in  front  to  the  level  of  the  os  internum,  and 
behind  to  'the  top  of  the  vagina,  from  which  points  it  is  reflected 
upwards  on  the  bladder  and  rectum  respectively.  At  the  sides  the 
peritoneal  investment  is  not  so  extensive,  for  a  little  below  the  level 
of  the  Fallopian  tubes  the  peritoneal  folds  separate  from  each  other, 
forming  the  broad  ligaments  (to  be  afterwards  described) ;  here  it  is 
that  the  vessels  and  nerves  supplying  the  uterus  gain  access  to  it. 
At  the  upper  part  of  the  organ  the  peritoneum  is  so  closely  adherent 

COLLIEG1E  01-  01=  &' 

l-K\  sicUKfc    J  K££' 


52 


ORGANS    CONCERNED    IN    PARTURITION. 


FlG.  20. 


to  the  muscular  tissue  that  it  cannot  be  separated  from  it ;  below  the 
connection  is  more  loose.     The  mass  of  the  uterine  tissue,  both  in 

the  body  and  cervix,  consists  of 
unstriped  muscular  fibres,  firmly 
united  together  by  nucleated  con- 
nective tissue  and  elastic  fibres. 
The  muscular  fibre  cells  are  large 
and  fusiform,  with  very  attenuated 
extremities,  generally  containing 
in  their  centre  a  distinct  nucleus. 
These  cells,  as  well  as  their  nuclei, 
become  greatly  enlarged  during 
pregnancy  (Fig.  21);  according  to 
Strieker,  this  is  only  the  case  with 
the  muscular  fibres  which  play  an 
important  part  in  the  expulsion  of  the  foetus,  those  of  the  outermost 
and  innermost  layers  not  sharing  in  the  increase  of  size.1  In  addi- 
tion to  these  developed  fibres  there  are,  especially  near  the  mucous 
coat,  a  number  of  round  elementary  corpuscles,  which  are  believed 


FIG.  21. 


Muscular  Fibres  of  unimpregnated  Uterus. 

(After  Farre.) 

a.   Fibres   united  by  connective   tissue,    b. 
Separate  fibres  and  elementary  corpuscles. 


Developed  Muscular  Fibres  from  the  Gravid  Uterus.     (After  Wagner.) 

by  Dr.  Farre2  to  be  the  elementary  form  of  the  muscular  fibres,  and 
which  he  has  traced  in  various  intermediate  states  of  development. 
Dr.  John  Williams3  believes  that  a  great  part  of  the  muscular  tissue 
of  the  uterus,  rather  more  indeed  than  three-fourths  of  its  thickness, 
is  an  integral  part  of  the  mucous  membrane,  analogous  to  the  mus- 
cularis  mucosae  of  the  mucous  membrane  of  the  alimentary  canal. 
This  he  describes  as  being  separated  from  the  rest  of  the  muscular 
tissue  by  a  layer  of  rather  loose  connective  tissue,  containing  nume- 
rous vessels.  In  early  foetal  life,  and  in  the  uteri  of  some  of  the 
lower  animals,  this  appearance  is  very  distinct ;  in  the  adult  female 
uterus,  however,  it  cannot  be  readily  made  out. 

Arrangement  of  the  Muscular  Fibres. — On  examining  the  uterine 
tissue  in  an  unimpregnated  condition  no  definite  arrangement  of  its 
muscular  fibres  can  be  made  out,  and  the  whole  seem  blended  in  in- 
extricable confusion.  By  observation  of  their  relations  when  hyper- 

1  Comparative  Histology,  vol.  iii.,  Syd.  Soc.  Trans.,  p   477. 

2  The  Uterus  and  its  Appendages,  p.  632. 

3  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Obstet.  Journ., 
1875. 

• 


THE  FEMALE  GENERATIVE  ORGANS.  53 

trophied  during  pregnancy,  He'lie1  lias  shown  that  they  may,  speaking 
roughly,  be  divided  into  three  layers :  an  external ;  a  middle,  chiefly 
longitudinal ;  and  an  internal,  chiefly  circular.  Into  the  details  of 
their  distribution,  as  described  by  him,  it  is  needless  to  enter  at  length. 
Briefly,  however,  he  describes  the  external  layer  as  arising  posteriorly 
at  the  junction  of  the  body  and  cervix,  and  spreading  upwards  and 
over  the  f'undus.  From  this  are  derived  the  muscular  fibres  found  in 
the  broad  and  round  ligaments,  and  more  particularly  described  by 
Kouget.  The  middle  layer  is  made  up  of  strong  fasciculi,  which  run 
upwards,  but  decussate  and  unite  with  each  other  in  a  remarkable 
manner,  so  that  those  which  are  at  first  superficial  become  most 
deeply  seated,  and  vice  versa.  The  muscular  fasciculi  which  form 
this  coat  curve  in  a  circular  manner  around  the  large  veins,  so  as  to 
form  a  species  of  muscular  canal  through  which  they  run.  This 
arrangement  is  of  peculiar  importance,  as  it  affords  a  satisfactory  ex- 
planation of  the  mechanism  by  which  hemorrhage  after  delivery  is 
prevented.  The  internal  layer  is  mainly  composed  of  circular  rings 
of  muscular  fibres,  beginning  round  the  openings  of  the  Fallopian 
tubes,  and  forming  wider  and  wider  circles  which  eventually  touch 
and  interlace  with  each  other.  They  surround  the  internal  os,  to 
which  they  form  a  kind  of  sphincter.  In  addition  to  these  circular 
fibres  on  the  internal  uterine  surface,  both  anteriorly  and  posteriorly, 
there  is  a  well-marked  triangular  layer  of  longitudinal  fibres,  the 
base  being  above  and  the  apex  below,  which  sends  muscular  fasciculi 
into  the  mucous  membrane. 

Its  Mucous  Membrane. — The  anatomy  of  the  lining  membrane  of 
the  uterus  has  been  the  subject  of  considerable  discussion.  Its  exist- 
ence has  been  denied  by  many  authorities,  most  recently  by  Snow 
Beck,2  who  maintains  that  it  is  in  no  sense  a  mucous  membrane,  but 
only  a  softened  portion  of  true  uterine  tissue.  It  is,  however,  pretty 
generally  admitted  by  the  best  authorities  that  it  is  essentially  a  mu- 
cous membrane,  differing  from  others  only  in  being  more  closely 
adherent  to  the  subjacent  structures,  in  consequence  of  not  possess- 
ing any  definite  connective  tissue  framework. 

It  is  a  pale  pink  membrane  of  considerable  thickness,  most  marked 
at  the  centre  of  the  body,  where  it  forms  from  |th  to  ^th  of  the 
thickness  of  the  whole  uterine  walls.  At  the  internal  os  uteri  it  ter- 
minates by  a  distinct  border,  which  separates  it  from  the  mucous 
membrane  lining  the  cervical  cavity. 

The  Utricular  Glands. — On  the  surface  of  the  mucous  membrane 
may  be  observed  a  multitude  of  little  openings,  about  ^ih  of  a  line 
in  width  (Fig.  22).  These  are  the  orifices  of  the  utricular  glands, 
which  are  found  in  immense  numbers  all  over  the  cavity  of  the 
uterus,  and  very  closely  agglomerated  together.  They  are  little  culs- 
de-sac,  narrower  at  their  mouths  than  in  their  length,  the  blind  ex- 
tremities of  which  are  found  in  the  subjacent  tissues.  Williams 
describes  them  as  running  obliquely  towards  the  surface  at  the  lower 

1  Recherches  sur  la  disposition  des  Fibres  musculaSres  de  1'Uterus.     Paris,  1869. 

2  Obst.  Trans.,  vol.  xiii.  p.  294. 


ORGANS    CONCERNED    IN    PARTURITION. 


third  of  the  cavity,  perpendicularly  at  its  middle,  while  towards  the 
fundus  they  are  at  first  perpendicular,  and  then  oblique   in  their 


FIG.  22. 


FIG.  23. 


Lining  Membrane  of  Uterus,  showing  network  of  Capillaries  and  Orifices  of  Uterine  Glands. 

(After  Farre.) 
From  the  body.  From  orifice  of  Fallopian  tube. 

course  (Fig.  23).  By  others  they  are  described  as  being  often  twisted 
and  corkscrew-like.  One  or  more  may  unite  to  form  a  common 
orifice,  several  of  which  may  open  together  in  little  pits  or  depres- 
sions on  the  surface  of  the  mucous  membrane.  These  glands  are 

composed  of  structureless  membrane  lined 
with  epithelium,  the  precise  character  of 
which  is  doubtful.  By  some  it  is  described 
as  columnar,  by  others  tesselated,  and  by 
some  again  as  ciliated.  The  most  gener- 
ally received  opinion  is  that  it  is  columnar. 
but  not  ciliated ;  therein  differing  from 
the  epithelium  covering  the  surface  of  the 
membrane,  which  is  undoubtedly  ciliated, 
the  movements  of  the  cilia  being  from 
Avithin  outAvards.  Williams,  hoAvever,  has 
observed  cilia  in  active  movement  on  the 
columnar  epithelium  lining  the  glands,  and 
also  states  that  at  the  deep-seated  extremi- 
ties of  the  glands,  which  penetrate  between 
the  muscular  fibres  for  some  distance,  the 
columnar  epithelium  is  replaced  by  rounded 
cells.  The  capillaries  of  the  mucous  mem- 
brane run  down  betAAreen  the  tubes,  form- 
ing a  lace-work  on  their  surfaces,  and 
round  their  orifices.  No  true  papillae  exist 
in  the  membrane  lining  the  uterine  cavity. 
The  mucous  membrane  of  the  uterus  is 
peculiar  in  being  always  in  a  state  of 
change  and  alteration,  being  thrown  oft' at 
each  menstrual  period  in  the  form  of  ddbris. 
in  consequence  of  fatty  degeneration  of  its 
structures,  and,  reformed  afresh  by  pro- 
liferation of  the  cells  of  the  muscular  and 
connective  tissues,  probably  from  beloAv 
upAvards,  the  neAv  membrane  commencing 
Hence  its  appearance  and  structure  vary  consid- 


The  course  of  the  Glands  in  the 
fully  developed  Mucous  Mem- 
brane of  the  Uterus,  viz.,  just  be- 
fore the  onset  of  a  menstrual 
period.  (After  Williams.) 


at  the  internal  os. 


THE  FEMALE  GENERATIVE  ORGANS.  55 

crably  according  to  the  time  at  which  it  is  examined.  This  subject, 
however,  will  be  more  particularly  studied  in  connection  with  men- 
struation. 

Mucous  Membrane  of  the  Cervix. — The  mucous  membrane  of  the 
cervix  is  much  thicker  and  more  transparent  than  that  of  the  bodv 
of  the  uterus,  from  which  it  also  differs  in  certain  structural  peculiari- 
ties. The  general  arrangements  of  its  folds  and  surface  have  alrcady 
been  described.  The  lower  half  of  the  membrane  lining  the  cavity  of 
the  cervix,  and  the  whole  of  that  covering  its  external  or  vaginal  por- 
tion, are  closely  set  with  a  large  number  of  minute  filiform,  or  clavate 
papillae  (Fig.  24).  Their  structure  is  similar  to  that  of  the  mucous 

FIG.  24. 


Villi  of  Os  Uteri  stripped  of  Epithelium.     (After  Tyler  Smith  aud  Hassall.) 

membrane  itself,  of  which  they  seem  to  be  merely  elevations.  They 
each  contain  a  vascular  loop  (Fig.  25),  and  they  are  believed  by 
Kilian  and  Farre  to  be  mainly  concerned  in  giving  sensibility  to  this 
part  of  the  generative  tract.  All  over  the  interior  of  the  cervix, 
both  on  the  ridges  of  the  mucous  membrane  and  between  their  folds, 
are  a  very  large  number  of  mucous  follicles,  consisting  of  a  structure- 
less membrane  lined  with  cylindrical  epithelium,  and  intimately 
united  with  the  connective  tissue.  They  cease  at  the  external  orifice 
of  the  cervix,  and  they  secrete  the  thick,  tenacious,  and  alkaline 
mucus  which  is  generally  found  filling  the  cervical  cavity.  The 
transparent  follicles,  known  as  the  "ovula  Nabothii"  which  are  some- 
times found  in  considerable  numbers  in  the  cavity  of  the  cervix,  con- 
sist of  mucous  follicles  the  mouths  of  which  have  become  obstructed, 
and  their  canals  distended  by  mucous  secretion.  The  lower  third 


OO  ORGANS    CONCERNED    IN    PARTURITION. 

of  the  cervical  canal,  as  well  as  the  exterior  of  the  cervix,  are  covered 
with  pavement  epithelium ;  while  on  its  upper  portion  is  found  a 
columnar  and  ciliated  epithelium  similar  to  that  lining  the  uterine 
cavity. 

FIG.  25. 


Villi  of  uterus,  covered  with  Pavement  Epithelium,  and  containing  Looped  Vessels.    (After  Tyler 

Smith  and  Hassall.) 

Vessels  of  the  Uterus. — The  arteries  of  the  uterus  are  derived  from 
the  internal  iliac,  and  from  the  ovarian.  They  enter  the  uterus  be- 
tween the  folds  of  the  broad  ligaments,  and,  penetrating  its  muscular 
coat,  anastomose  freely  with  each  other  and  with  the  corresponding 
vessels  of  the  opposite  side.  Their  walls  are  thick  and  well-devel- 
oped, and  they  are  remarkable  for  their  very  tortuous  course,  forming 
spiral  curves,  especially  in  the  upper  part  of  the  uterus.  They  end 
in  minute  capillaries  which  form  the  fine  meshes  surrounding  the 
glands,  and  in  the  cervix,  give  off'  the  loops  entering  the  papillae. 
Beneath  the  uterine  mucous  membrane  these  capillaries  form  a  plexus, 
terminating  in  veins  without  valves,  which  unite  with  each  other  to 
form  the  large  veins  traversing  the  substance  of  the  uterus,  known 
during  pregnancy  as  the  uterine  sinuses,  the  walls  of  which  are  closely 
adherent  to  the  uterine  tissues.  These  veins,  freely  anastomosing 
with  each  other,  pass  outwards  to  the  folds  of  the  broad  ligaments, 
where  they  unite  to  form,  with  the  ovarian  and  vaginal  veins,  a  large 
and  well-developed  venous  network,  known  as  the  pampiniform 
plexus. 

Lymphatics  of  the  Uterus. — The  lymphatics  of  the  uterus  are  large 
and  well  developed,  and  they  have  recently,  and  with  much  proba- 
bility, been  supposed  to  play  an  important  part  in  the  production  of 
certain  puerperal  diseases.  A  more  minute  knowledge  than  we  at 


THE  FEMALE  GENERATIVE  ORGANS.  57 

present  possess  of  their  course  and  distribution  will  probably  throw 
much  light  on  their  influence  in  this  respect.  According  to  the  re- 
searches of  Leopold,1  who  has  studied  their  minute  anatomy  care- 
fully, they  originate  in  lymph  spaces  between  the  fine  bundles  of 
connective  tissue  forming  the  basis  of  the  mucous  lining  of  the  uterus. 
Here  they  are  in  intimate  contact  with  the  utricular  glands  and  the 
ultimate  ramifications  of  the  uterine  bloodvessels.  As  they  pass 
into  the  muscular  tissue  they  become  gradually  narrowed  into  lymph 
vessels  and  spaces,  which  have  a  very  complicated  arrangement,  and 
which  eventually  unite  together  in  the  external  muscular  layer,  espe- 
cially on  the  sides  of  the  uterus,  to  form  large  canals  which  probably 
have  valves.  Immediately  under  the  peritoneal  covering  these 
lymph-vessels  form  a  large  and  characteristic  network,  covering  the 
anterior  and  posterior  surfaces  of  the  uterus,  and  present,  in  various 
parts  of  their  course,  large  ampullae.  They  then  spread  over  the 
Fallopian  tubes.  The  lymphatics  of  the  body  of  the  uterus  unite 
with  the  lumbar  glands,  those  of  the  cervix  with  the  pelvic  glands. 

Nerves  of  the  Uterus. — The  distribution  and  arrangement  of  the 
nerves  of  the  uterus  have  been  the  subject  of  much  controversy. 
They  are  derived  mainly  from  the  ovarian  and  hypogastric  plexuses, 
inosculating  freely  with  each  other  between  the  folds  of  the  broad  liga- 
ment, from  which  they  enter  the  muscular  tissue  of  the  uterus  gene- 
rally, but  not  invariably,  following  the  course  of  the  arteries.  They 
are  chiefly  derived  from  the  sympathetic;  but,  as  the  hypogastric 
plexus  is  connected  with  the  sacral  nerves,  it  is  probable  that  some 
fibres  from  the  cerebro-spinal  system  are  distributed  to  the  cervix. 
It  is  now  generally  admitted  that  nervous  filaments  are  distributed 
to  the  cervix,  even  as  far  as  the  external  os  although  their  existence 
in  this  situation  has  been  denied  by  Jobert  and  other  writers.  The 
ultimate  distribution  of  the  nerves  is  not  yet  made  out.  Polle  de- 
scribes a  nerve  filament  as  entering  the  papillae  of  the  cervical  mu- 
cous membrane  along  with  the  capillary  loop,  and  Frankenhauser 
says  the  nerve  fibres  surround  the  muscles  of  the  uterus  in  the  form 
of  plexuses  and  terminate  in  the  nuclei  of  the  muscle  cells. 

Anomalies  of  the  Uterus. — Various  abnormal  conditions  of  the 
uterus  and  vagina  are  occasionally  met  with,  which  it  is  necessary 
to  mention,  as  they  may  have  an  important  practical  bearing  on 
parturition.  The  most  frequent  of  these  is  the  existence  of  a  double, 
or  partially  double,  uterus  (Fig.  26),  similar  to  that  found  normally 
in  many  of  the  lower  animals.  This  abnormality  is  explained  by  the 
development  of  the  organ  during  foetal  life.  The  uterus  is  formed 
out  of  structures  existing  only  in  early  foetal  life,  known  as  the 
Wolfian  bodies.  These  consist  of  a  number  of  tubes,  situated  on 
either  side  of  the  vertebral  column,  and  opening  internally  into  an 
excretory  duct.  Along  their  external  border  a  hollow  canal  is 
formed,  termed  the  canal  of  Miiller,  which  like  the  excretory  ducts, 
proceeds  to  the  common  cloaca  of  the  digestive  and  urinary  organs 
which  then  exists.  The  canal  of  Miiller  unites  with  its  fellow  of  the 

1  Arch.  f.  Gvnak.  Bd.  vi.  Heft  i. 


58  ORGANS    CONCERNED    IN    PARTURITION. 

opposite  side  to  form  the  uterus  and  Fallopian  tubes  in  the  female, 
and  subsequently  the  central  partition  at  their  point  of  junction  dis- 
appears. If,  however,  the  progress  of  development  be  in  any  way 
checked,  the  central  partition  may  remain.  Then  we  have  produced 

FIG.  26. 


v^f^fKffB 

Bifld  Uterus.     (After  Fiirre.) 

either  a  complete  double  uterus  or  the  uterus  bicornis,  which  is  bifid 
at  its  upper  extremity  only;  or  a  double  vagina,  each  leading  to 
a  separate  uterus! 

Pregnancy  in  cases  of  Bifid  Uterus. — If  pregnancy  occur  in  any  of 
these  anomalous  uteri,  and  many  such  cases  are  recorded,  serious 
troubles  may  follow.  It  may  happen  that  one  horn  of  a  double 
uterus  is  not  sufficiently  large  to  admit  of  pregnancy  going  on  to 
term,  and  rupture  may  occur.  It  is  supposed  that  some  cases,  pre- 
sumed to  be  tubal  gestation,  were  really  thus  explicable.  Impreg- 
nation may  also  occur  in  the  two  cornua  at  different  times,  leading 
to  superfcetation.  It  is,  however,  quite  possible  that  impregnation 
may  occur  in  one  horn  of  a  bifid  uterus,  and  labor  be  completed  with- 
out anything  unusual  being  observed.  A  remarkable  case  of  this 
sort  has  been  recorded  by  Dr.  Ross  of  Brighton,1  in  which  a  patient 
miscarried  of  twins  on  July  16,  1870,  and  on  October  31,  fifteen  weeks 
later,  she  was  delivered  of  a  healthy  child.  Careful  examination 
showed  the  existence  of  a  complete  double  uterus,  each  side  of  which 
had  been  impregnated.  Curiously  enough,  this  patient  had  formerly 
given  birth  to  six  living  children  at  term,  nothing  remarkable  having 
been  observed  in  her  labors.  It  can  only  rarely  happen,  that,  under 
such  circumstances,  so  favorable  a  result  will  follow,  and  more  or 
less  difficulty  and  danger  may  generally  be  expected.  Occasionally 
the  vagina  only  is  double,  the  uterus  being  single.  Dr.  Matthews 
Duncan  has  recorded  some  cases  of  this  kind,2  in  which  the  vaginal 
septum  formed  an  obstacle  to  the  birth  of  the  child,  and  required 
division.  [It  may  also  be  associated  with  an  obstinate  form  of  vagi- 
nismus. — ED.] 

1  Lancet,  August,  1871. 

2  Researches  in  Obstetrics,  p.  443. 


THE  FEMALE  GENERATIVE  ORGANS.  i)\) 

Ligaments  of  the  Uterus. — The  various  folds  of  peritoneum  which 
invest  the  uterus  serve  to  maintain  it  in  position,  and  they  are  de- 
scribed as  its  ligaments.  They  are  the  broad,  the  vesico-uterine,  and 
sacro-uterine  ligaments  ;  the  round  ligaments  are  not  peritoneal  folds 
like  the  others. 

Broad  Ligaments. — The  broad  ligaments  extend  from  either  side 
of  the  uterus,  where  their  laminae  are  separated  from  each  other, 
transversely  across  to  the  pelvic  wall,  and  thus  divide  the  cavity  of 
the  pelvis  into  two  parts;  the  anterior  containing  the  bladder,  the 
posterior  the  rectum.  Their  upper  borders  are  divided  into  three 
subsidiary  folds,  the  anterior  of  which  contains  the  round  ligament, 
the  middle  the  Fallopian  tube,  and  the  posterior  the  ovary.  This 
arrangement  has  received  the  name  of  the  ala  vespertilioms,  from  its 
fancied  resemblance  to  a  bat's  wing.  Between  the  folds  of  the  broad 
ligaments  are  found  the  uterine  vessels  and  nerves,  and  a  certain 
amount  of  loose  cellular  tissue  continuous  with  the  pelvic  fasciae. 
Here  is  situated  that  peculiar  structure  called  the  organ  of  Eosen- 
miiller,  or  the  parovarium  (Fig.  27),  which  is  the  remains  of  the 

FIG.  27. 


Adult  Parovarium,  Ovary,  and  Fallopian  Tube.     (After  Kobelt.) 

Wolffian  body,  and  corresponds  to  the  epididymis  in  the  male.  This 
may  best  be  seen  in  young  subjects,  by  holding  up  the  broad  liga- 
ments and  looking  through  them  by  transmitted  light;  but  it  exists 
at  all  ages.  It  consists  of  several  tubes  (eight  or  ten  according  to 
Farre,  eighteen  or  twenty  according  to  Bankes),1  which  are  tortuous 
in  their  course.  They  are  arranged  in  a  pyramidal  form,  the  base 
of  the  pyramid  being  towards  the  Fallopian  tube,  its  apex  being  lost 
on  the  surface  of  the  ovary.  They  are  formed  of  fibrous  tissue,  and 
lined  with  pavement  epithelium.  They  have  no  excretory  duct,  or 
communication  with  either  the  uterus  or  ovary,  and  their  function, 
if  they  have  any,  is  unknown. 

'  Bankes,  On  the  Wolffian  Bodies. 


1)0  ORGANS    CONCERNED    IN    PARTURITION. 

Muscular  Fibres  between  its  Folds. — A  number  of  muscular  fibres 
are  also  found  in  this  situation,  lying  between  the  meshes  of  the 
connective  tissue.  They  have  been  particularly  studied  by  liouget, 
who  describes  them  as  interlacing  with  each  other,  and  forming  an 
open  network,  continuous  with  the  muscular  tissue  of  the  uterus 

FIG.  28. 


Posterior  View  of  Muscular  and  Vascular  Arrangements.     (After  Rouget.) 

Vessels.  —  1,  2,3.  Vaginal,  cervical,  aud  uterine  plexuses.  4.  Arteries  of  body  of  uterus.  5.  Arteries 
supplying  ovary.  Mvscular  fasciculi. — 6,  7.  Fibres  attached  to  vagina,  symphysis  pubi.i,  and  saero- 
iliac  joint  8.  Muscular  fasciculi  from  uterus  and  broad  ligaments.  9,10,11,12.  Fasciculi  att;u-h<-d 
to  ovary  aud  Fallopian  tubes. 

(Fig.  28).  They  are  divisible  into  two  layers,  the  anterior  of  Avhich 
is  continuous  with  the  muscular  fibres  of  the  anterior  surface  of  the 
uterus,  and  goes  to  form  part  of  the  round  ligament;  the  posterior 
arises  from  the  posterior  wall  of  the  uterus,  and  proceeds  transversely 
outwards,  to  become  attached  to  the  sacro-iliac  synchondrosis.  A 
continuous  muscular  envelope  is  thus  formed,  which  surrounds  the 
whole  of  the  uterus,  Fallopian  tubes,  and  ovaries.  Its  function  is 
not  yet  thoroughly  established.  It  is  supposed  to  have  the  effect  of 
retracting  the  stretched  folds  of  peritoneum  after  delivery,  and  more 
especially  of  bringing  the  entire  generative  organs  into  harmouius 
action  during  menstruation  and  the  sexual  orgasm;  in  this  way 
explaining,  as  we  shall  subsequently  see,  the  mechanism  by  which 


THE  FEMALE  GENERATIVE  ORGANS.  (51 

the  fimbriated  extremity  of  the  Fallopian  tube  grasps  the  ovarv 
prior  to  the  rupture  of  a  Graafian  follicle. 

Round  Ligaments.— -The  round  ligaments  are  essentially  muscular 
in  structure.  They  extend  from  the  upper  border  of  the  uterus, 
with  the  fibres  of  which  their  muscular  fibres  are  continuous,  trans- 
versely and  then  obliquely  downwards,  until  they  reach  the  inguinal 
rings,  where  they  blend  with  the  cellular  tissue.  In  the  first  part  of 
their  course  the  muscular  fibres  are  solely  of  the  unstriped  variety, 
but  soon  they  receive  striped  fibres  from  the  transversalis  muscles, 
and  the  columns  of  the  inguinal  ring,  which  surround  arid  cover  the 
unstriped  muscular  tissue.  In  addition  to  these  structures  they  con- 
tain elastic  and  connective  tissue,  and  arterial,  venous,  and  nervous 
branches  ;  the  former  form  the  iliac  or  cremasteric  arteries,  the  latter 
the  genito-crural  nerve.  According  to  Mr.  Kainey  the  principal 
function  of  these  ligaments  is  to  draw  the  uterus  towards  the  sym- 
physis  pubis  during  sexual  intercourse,  and  thus  to  favor  the  ascent 
of  the  semen. 

Vesico-uterine  Ligaments. — The  vesico-uterine  ligaments  are  two 
folds  of  peritoneum  passing  in  front  from  the  lower  part  of  the  body 
of  the  uterus  to  the  fundus  of  the  bladder. 

Utero-sacral  Ligaments. — The  utero-sacral  ligaments  consist  of 
folds  of  peritoneum  of  a  crescentic  form,  with  their  concavities  look- 
ing inwards :  they  start  from  the  lower  part  of  the  posterior  surface 
of  the  uterus,  and  curve  backwards  to  be  attached  to  the  third  and 
fourth  sacral  vertebrge.  Within  their  folds  exist  bundles  of  muscu- 
lar fibres,  continuous  with  those  of  the  uterus,  as  well  as  connective 
tissue,  vessels,  and  nerves.  The  experiments  of  Savage,  as  well  as 
of  other  anatomists,  show  that  these  ligaments  have  an  important 
influence  in  preventing  downward  displacement  of  the  womb. 

Alterations  during  Pregnancy. —During  pregnancy  all  these  liga- 
ments become  greatly  stretched  and  unfolded,  rising  out  of  the  pelvic 
cavity  and  accommodating  themselves  to  the  increased  size  of  the 
gravid  uterus ;  and  they  again  contract  to  their  natural  size,  possibly 
through  the  agency  of  the  muscular  fibres  contained  within  them, 
after  delivery  has  taken  place. 

Fallopian  Tubes. — The  Fallopian  tubes,  the  homologues  of  the  vasa 
defereritia  in  the  male,  are  structures  of  great  physiological  interest. 
They  serve  the  double  purpose  of  conveying  the  semen  to  the  ovary, 
and  of  carrying  the  ovule  to  the  uterus.  From  the  latter  function 
they  may  be  looked  on  as  the  excretory  ducts  of  the  ovaries ;  but, 
unlike  other  excretory  ducts,  they  are  movable,  so  that  they  may 
apply  themselves  to  the  part  of  the  ovaries  from  which  the  ovule  is 
to  come  ;  and  so  great  is  their  mobility,  that  there  is  reason  to  believe 
that  a  Fallopian  tube  may  even  grasp  the  ovary  of  the  opposite  side. 
[This  has  been  established  by  a  case  where  impregnation  took  place 
in  an  ovary,  the  Fallopian  tube  corresponding  to  which  was  imper- 
vious and  immovable. — ED.]  Each  tube  proceeds  from  the  upper 
angle  of  the  uterus  at  first  transversely  outwards,  and  then  down- 
wards, backwards,  and  inwards,  so  as  to  reach  the  neighborhood  of 
the  ovary.  In  the  first  part  of  its  course  it  is  straight,  afterwards  it 


62 


ORGANS    CONCERNED    IN    PARTURITION. 


becomes  flexuous  and  twisted  on  itself.  It  is  contained  in  the  upper 
part  of  the  broad  ligament,  where  it  may  be  felt  as  a  hard  cord.  It 
commences  at  the  uterus  by  a  narrow  opening,  admitting  only  the 
passage  of  a  bristle,  known  as  the  ostium  uterinum.  As  it  passes 
through  the  muscular  walls  of  the  uterus  the  tube  takes  a  somewhat 
curved  course,  and  opens  into  the  uterine  cavity  by  a  dilated  aper- 
ture. From  its  uterine  attachment  the  tube  expands  gradually  until 
it  terminates  in  its  trumpet-shaped  extremity ;  just  before  its  distal 
end,  however,  it  again  contracts  slightly.  The  ovarian  end  of  the 
tube  is  surrounded  by  a  number  of  remarkable  fringe-like  processes. 
These  consist  of  longitudinal  membranous  fimbriaj,  surrounding  the 
aperture  of  the  tube,  like  the  tentacles  of  a  polyp,  varying  conside- 
rably in  number  and  size,  and  having  their  edges  cut  and  subdivided. 
On  their  inner  surface  are  found  both  transverse  and  longitudinal 
folds  of  mucous  membrane,  continuous  with  those  lining  the  tube 
itself  (Fig.  29).  One  of  these  fimbriae  is  always  larger  and  more  de- 

FIG.  29. 


Fallopian  Tube  laid  open      (After  Richard.) 

a,  b.  Uterine  portion  of  Tube,     c,  d.  Plicae  of  Mucous  Membrane,    t.  Tuba-ovarian  Ligaments  and 
Fringes.    /.  Ovary,    g.  Kouud  Ligament*. 

veloped  than  the  rest,  and  is  indirectly  united  to  the  surface  of  the 
ovary  by  a  fold  of  peritoneum  proceeding  from  its  external  surface. 
Its  under  surface  is  grooved  so  as  to  form  a  channel,  open  below. 
The  function  of  this  fringe-like  structure  is  to  grasp  the  ovary  during 
the  menstrual  nisus ;  and  the  fimbria  which  is  attached  to  the  ovary 
would  seem  to  guide  the  tentacles  to  the  ovary  which  they  are  in- 
tended to  seize.  One  or  more  supplementary  series  of  fimbriae  some- 
times exist,  which  have  an  aperture  of  communication  with  the  canal 
of  the  Fallopian  tube,  beyond  its  ovarian  extremity. 

Their  Structure. — The  tubes  themselves  consist  of  peritoneal,  mus- 
cular, and  mucous  coats.  The  peritoneum  surrounds  the  tube  for 
three-fourths  of  its  calibre,  and  comes  into  contact  with  the  mucous 


THE  FEMALE  GENERATIVE  ORGANS.  03 

lining  at  its  fimbriated  extremity,  the  only  instance  in  the  body 
where  such  a  junction  occurs.  The  muscular  coat  is  principally 
composed  of  circular  fibres,  with  a  few  longitudinal  fibres  inter- 
spersed. Its  muscular  character  has  been  doubted  by  Robin  and 
Richard,  but  Farre  had  no  difficulty  in  demonstrating  the  existence 
of  muscular  fibres,  both  in  the  human  female  and  many  of  the  lower 
animals.  According  to  Robin  the  muscular  tissue  of  the  Fallopian 
tubes  is  entirely  distinct  from  that  of  the  uterus,  from  which  he 
describes  it  as  being  separated  by  a  distinct  cellular  septum.  The 
mucous  lining  is  thrown  into  a  number  of  remarkable  longitudinal 
folds,  each  of  which  contains  a  dense  and  vascular  fibrous  septum, 
with  small  muscular  fibres,  and  is  covered  with  columnar  and  ciliated 
epithelium.  The  apposition  of  these  produces  a  series  of  minute 
capillary  tubes,  along  which  the  ovules  are  propelled,  the  action  of 
the  cilia,  which  is  towards  the  uterus,  apparently  favoring  their 
progress. 

The  Ovaries. — The  ovaries  are  the  bodies  in  which  the  ovules  are 
formed,  and  from  which  they  are  expelled,  and  the  changes  going  on 
in  them,  in  connection  with  the  process  of  ovulation,  during  the 
whole  period  between  the  establishment  of  puberty  and  the  cessation 
of  menstruation,  have  an  enormous  influence  on  the  female  economy. 
Normally,  the  ovaries  are  two  in  number;  in  some  exceptional  cases 
a  supplementary  ovary  has  been  discovered  ;  or  they  may  be  entirely 
absent.  They  are  placed  in  the.  posterior  fold  of  the  broad  ligament, 
usually  below  the  brim  of  the  pelvis,  behind  the  Fallopian  tubes,  the 
left  in  front  of  the  rectum,  the  right  in  front  of  some  coils  of  the 
small  intestine.  Their  situation  varies,  however,  very  much  under 
different  circumstances,  so  that  they  can  scarcely  be  said  to  have  a 
fixed  arid  normal  position.  In  pregnancy  they  rise  into  the  abdomi- 
nal cavity  with  the  enlarging  uterus.;  and  in  certain  conditions  they 
are  dislocated  downwards  into  Douglas's  space,  where  they  may  be 
felt  through  the  vagina  as  rounded  and  very  tender  bodies. 

Their  Connections. — The  folds  of  the  broad  ligament,  between  which 
the  ovaries  are  placed,  form  for  them  a  kind  of  loose  mesentery. 
Each  of  them  is  united  to  the  upper  angle  of  the  uterus  by  a  special 
ligament  called  the  utero-ovarian.  This  is  a  rounded  band  of  organic 
muscular  fibres,  about  an  inch  in  length,  continuous  with  the  super- 
ficial muscular  fibres  of  the  posterior  wall  of  the  uterus,  and  attached 
to  the  inner  extremity  of  the  ovary.  It  is  surrounded  by  peritoneum, 
and  through  it  the  muscular  fibres,  which  form  an  important  integral 
part  in  the  structure  of  the  ovaries,  are  conveyed  to  them.  The 
ovary  is  also  attached  to  the  fimbriated  extremity  of  the  Fallopian 
tube  in  the  manner  already  described. 

The  ovary  is  of  an  irregular  oval  shape  (Fig.  30),  the  upper  bor- 
der being  convex,  the  lower — through  which  the  vessels  and  nerves 
enter — being  straight.  The  anterior  surface,  like  that  of  the  uterus, 
is  less  convex  than  the  posterior.  The  outer  extremity  is  more 
rounded  and  bulbous  than  the  inner,  which  is  somewhat  pointed  and 
eventually  lost  in  its  proper  ligament.  By  these  peculiarities  it  is 
possible  to  distinguish  the  left  from  the  right  ovary,  after  they  have 


64 


ORGANS    CONCERNED    IN    PARTURITION. 


been  removed  from  the  body.  The  ovary  varies  much  in  size  under 
different  circumstances.  Oil  an  average,  in  adult  life,  it  measures 
from  one  to  two  inches  in  length,  three-quarters  of  an  inch  in  width, 
and  about  half  an  inch  in  thickness.  It  increases  greatly  in  size 
during  each  menstrual  period :  a  fact  which  has  been  demonstrated 
in  certain  cases  of  ovarian  hernia,  where  the  protruded  ovary  has 
been  seen  to  swell  as  menstruation  commenced;  also  during  preg- 
nancy, when  it  is  said  to  be  double  its  usual  size.  After  the  change  of 
life  it  atrophies,  and  becomes  rough  and  wrinkled  on  its  surface.  Be- 

FIG.  30. 


—  A 


A  A.  Ovary  enlarged  under  Menstrual  Xisus.     B.  Ripe  Follicle  projecting  on  its   surface,     a,  a,  a. 
Traces  of  previously  ruptured  Follicles. 

fore  puberty,  the  surface  of  the  ovary  is  smooth  and  polished,  and  of 
a  whitish  color.  After  menstruation  commences,  its  surface  becomes 
scarred  by  the  rupture  of  the  Graafian  follicles  (Fig.  30,  A  A),  each 
of  which  leaves  a  little  linear  or  striated  cicatrix,  of  a  brownish 
color ;  and  the  older  the  patient  the  greater  are  the  number  of  these 
cicatrices. 

Structure. — The  structure  of  the  ovary  has  been  made  the  subject 
of  many  important  observations.  It  has  an  external  covering  of 
epithelium,  originally  continuous  with  the  peritoneum,  called  by 
some  the  germ-epithelium,  in  consequence  of  the  ovules  being  formed 
from  it  in  early  foetal  life.  In  the  adult  it  is  separated  from  the  peri- 
toneum at  the  base  of  the  organ  by  a  circular  white  line,  and  it  con- 
sists of  columnar  epithelium,  differing  only  from  the  epithelium 
lining  the  Fallopian  tubes,  with  which  it  is  sometimes  continuous 
through  the  attached  fimbria  uniting  the  tube  and  the  ovary,  in  being 
destitute  of  cilia.  Immediately  beneath  this  covering  is  the  dense 
coat  known  as  the  tunica  albuyinea,  on  account  of  its  whitish  color. 
It  consists  of  short  connective-tissue  fibres,  arranged  in  laminae,  among 
which  are  interspersed  fusiform  muscular  fibres.  At  the  point  where 
the  vessels  and  nerves  enter  the  ovary  this  membrane  is  raised  into 
a  ridge,  which  is  continuous  with  the  utero-ovarian  ligament.  The 


THE  FEMALE  GENERATIVE  ORGANS.  bJ) 

tunica  albuginea  is  so  intimately  blended  with  the  stronia  of  the 
ovary,  as  to  be  inseparable  on  dissection ;  it  does  not,  however,  exist 
as  a  distinct  lamina,  but  is  merely  the  external  part  of  the  proper 
structure  of  the  ovary,  in  which  more  dense  connective  tissue  is 
developed  than  elsewhere. 

The  Stroma. — On    making   a   longitudinal  section    of  the    ovary 
(Fig.  31).  it  will  be  seen  to  be  composed  of  two  parts,  the  more  internal 
of  which  is  of  a  reddish  color  from  the  num- 
ber of  vessels  that  ramify  in  it,  and  is  called  FIG.  si . 
the  medullary  or  vascular  zone  ;  while  the 
external,   of  a  whitish   tint,   receives  the 
name   of  the   cortical   or    parenchymatous 
substance.     The  former  consists    of  loose 
connective  tissue  interspersed  with  elastic, 
and  a   considerable   number  of  muscular 
fibres.      According   to   Eouget1   and    His2 
the  muscular  structure  forms  the  greater 
part  of  the  ovarian  stroma.     The  latter  de- 
scribes it  as  consisting  essentially  of  inter- 
woven  muscular   fibres,  which   he   terms 

,,  f,      •(,  .  11  i          1-11          i  Longitudinal  section  of  adult 

the     "lUSltorm    tlSSUe,        and    Which     he     be-  ovary.     (After  Farre.) 

lieves  to  be  continuous  with  the  muscular 

layers  of  the  ovarian  vessels.  The  former  believes  that  the  mus- 
cular fasciculi  accompany  the  vessels  in  the  form  of  sheaths,  as  in 
erectile  tissues.  Both  attribute  to  the  muscular  tissues  an  important 
influence  in  the  expulsion  of  the  ovules,  and  in  the  rupture  of  the 
Graafian  follicles.  Waldeyer  and  other  writers,  however,  do  not 
consider  it  to  be  so  extensively  developed  as  Rouget  and  His  believe. 
The  cortical  substance  is  the  more  important,  as  that  in  which  the 
Graafian  follicles  and  ovules  are  formed.  It  consists  of  interlaced 
fibres  of  connective  tissue,  containing  a  large  number  of  nuclei.  The 
muscular  fibres  of  the  medullary  substance  do  not  seem  to  penetrate 
into  it  in  man.  In  it  are  found  the  Graafian  follicles,  which  exist  in 
enormous  numbers  from  the  earliest  periods  of  life,  and  in  all  stages 
of  development  (Fig.  32). 

The  Graafian  Follicles. — According  to  the  researches  of  Pflu'ger, 
Waldeyer,  and  other  German  writers, .  the  Graafian  follicles  are 
formed  in  early  foetal  life  by  cylindrical  inflections  of  the  epithelial 
covering  of  the  ovary,  which  dip  into  the  substance  of  the  gland. 
These  tubular  filaments  anastomose  with  each  other,  and  in  them 
are  formed  the  ovules,  which  are  originally  the  epithelial  cells  lining 
the  tubes.  Portions  become  shut  off'  from  the  rest  of  the  filaments, 
and  form  the  Graafian  follicles.  The  ovules,  on  this  view,  are  highly 
developed  epithelial  cells,  originally  derived  from  the  surface  of  the 
ovary,  and  not  developed  in  its  stroma.  These  tubular  filaments 
disappear  shortly  after  birth,  but  they  have  recently  been  detected 

1  Journal  de  Physiol.  i.  p.  737. 

2  Schultze's  Arch.  f.  Mikrocop.  Anat.  18G5. 


66 


ORGANS    CONCERNED    IN    PARTURITION. 


by  Slavyansky1  in  the    ovaries  of  a  woman  thirty  years  of  age. 
These  observations  have  been  modified  by  Dr.  Foulis,  in  a  recent 


FIG.  32. 


Section  through  the  Cortical  part  of  the  Ovary. 

e.  Surface  Epithelium,  s  s.  Ovarian  Stronio.  11.  Large-sized  Graafian  Follicles.  22.  Middle- 
sized,  and  3  3.  Small-sized  Graafian  Follicles.  o.  Ovule  within  Graaflan  Follicle,  v  v.  Bloodvessels 
in  the  Stroma.  g.  Cells  of  the  Membrana  Granulosa.  (After  Turner.) 


FlG.  33. 


Vertical  Section  through  the  Ovary  of  the  Human  Foetus. 

g  g.  Germ-epithelium,  with  o  o.  Developing  Ovules  in  it.  s  s.  Ovarian  Stroma,  containing  c  c  c. 
Fusiform  Connective  Tissue  Corpuscles,  vv.  Capillary  Bloodvessels.  In  the  centre  of  the  Figure 
an  Involution  of  the  Germ-epithelium  is  shown  ;  and  at  the  left  lower  side  a  Primordial  Ovule,  with 
the  Connective-tissue  Corpuscles  ranging  themselves  ronud  it.  (After  Foulis.) 

graduation  thesis,  communicated  to  the  Royal  Society  of  Edinburgh.2 
He  recognizes  the  origin  of  the  ovules  from  the  germ-epithelium 

1  Anmiles  de  Gynak,  Feb.  1871. 

2  Proceedings  of  the  Royal  Soc.  of  Edinb.,  April,  1875. 


THE  FEMALE  GENERATIVE  ORGANS. 


G7 


covering  the  surface  of  the  ovary,  which  is  itself  derived  from  the 
Wolffian  body.  He  believes  all  the  ovules  to  be  formed  from  the 
germ -epithelium  corpuscles,  which  become  embedded  in  the  stroma 
of  the  ovary,  by  the  outgrowth  of  processes  of  vascular  connective 
tissue,  fresh  germ-epithelial  corpuscles  being  constantly  produced  on 
the  surface  of  the  organ  up  to  the  age  of  2J  years,  to  take  the  place 
of  those  already  embedded  in  its  stroma.  He  believes  the  Grraafian 
follicles  to  be  formed  by  the  growth  of  delicate  processes  of  connec- 
tive tissue  between  and  around  the  ovules,  but  not  from  tubular  in- 
flections of  the  epithelium  covering  the  gland,  as  described  bv 
Waldeyer  (Fig.  33). 

The  greater  proportion  of  the  Grraafian  follicles  are  only  visible 
with  the  higher  powers  of  the  microscope,  but  those  which  are  ap- 
proaching maturity  are  distinctly  to  be  seen  by  the  naked  eye.  The 
quantity  of  these  follicles  is  immense.  Foulis  estimates  that  at  birth 
each  human  ovary  contains  not  less  than  30,000.  No  fresh  follicles 
appear  to  be  formed  after  birth,  and  as  development  goes  on  some 
only  grow,  and  by  pressure  on  the  others,  destroy  them.  Of  those 
that  grow  of  course  only  a  few  ever  reach  maturity ;  they  are  scat- 
tered through  the  substance  of  the  ovary,  some  developing  in  the 
stroma,  others  on  the  surface  of  the  organ,  where  they  eventually 
burst,  and  are  discharged  into  the  Fallopian  tube. 

Structure. — A  ripe  Graafian  follicle  has  an  external  investing  mem- 
brane (Fig.  34),  which  is  generally  described  as  consisting  of  two 

FIG.  34. 


Diagrammatic  Section  of  Graafian  Follicle. 

1.  Ovum.     2.   Membrana  granulosa.     3.   External  membrane  of  Graaflan  follicle.     4.    Its  vessels. 
5.  Ovarian  stroma.     6.  Cavity  of  Graafian  follicle.     7.     External  covering  of  ovary. 

distinct  layers;  the  external,  or  tunica  fibrosa,  highly  vascular  and 
formed  of  connective  tissue ;  the  internal,  or  tunica  propria,  composed 
of  young  connective  tissue,  containing  a  large  number  of  fusiform 
or  stellate  cells,  and  numerous  oil-globules.  These  layers,  however, 
appear  to  be  essentially  formed  of  condensed  ovarian  stroma.  Within 
this  capsule  is  the  epithelial  lining  called  the  ?nembrana  granulosa, 
consisting  of  stratified  columnar  epithelial  cells,  which,  according  to 
Foulis,  are  originally  formed  from  the  nuclei  of  the  fibre-nuclear 


68  ORGANS    CONCERNED    IN    PARTURITION. 

tissue  of  the  stroma  of  the  ovary.  At  one  part  of  the  circumference 
of  the  ovisac  is  situated  the  ovule,  around  which  the  epithelial  cells 
are  congregated  in  greater  quantity,  constituting  the  projection  known 
as  the  discus  proligerus.  The  remainder  of  the  cavity  of  the  follicle 
is  filled  with  a  small  quantity  of  transparent  fluid,  the  liquor  folUculi^ 
traversed  by  three  or  four  minute  bauds,  the  retinacula  of  Barry, 
which  are  attached  to  the  opposite  walls  of  the  follicular  cavity,  and 
apparently  serve  the  purpose  of  suspending  the  ovule,  and  main- 
taining it  in  a  proper  position.  In  many  young  follicles  this  cavity 
does  not  at  first  exist,  the  follicle  being  entirely  filled  by  the  ovule. 
According  to  "Waldeyer,  the  liquor  folliculi  is  formed  by  the  disinte- 
gration of  the  epithelial  cells,  the  fluid  thus  produced  collecting,  and 
distending  the  interior  of  the  follicle. 

Ovule. — The  ovule  is  attached  to  some  part  of  the  internal  surface 
of  the  Graafian  follicle.  It  is  a  rounded  vesicle  about  Ti0  of  an  inch 
in  diameter,  and  is  surrounded  by  a  layer  of  columnar  cells,  distinct 
from  those  of  the  discus  proligerus  in  which  it  lies.  It  is  invested 
by  a  transparent  elastic  membrane,  the  zona  pellucida,  or  vitelline 
membrane.  In  most  of  the  lower  animals  the  zoua  pellucida  is  per- 
forated by  numerous  very  minute  pores,  only  visible  under  the 
highest  powers  of  the  microscope ;  in  others  there  is  a  distinct  aper- 
ture of  a  larger  size,  the  micropyle,  allowing  the  passage  for  the 
spermatozoa  into  the  interior  of  the  ovule.  It  is  possible  that  similar 
apertures  may  exist  in  the  human  ovule,  but  they  have  not  been 
demonstrated.  Within  the  zona  pellucida  some  embryologists  de- 
scribe a  second  fine  membrane,  the  existence  of  which  has  been 
denied  by  Bischoff.  The  cavity  of  the  ovule  is  filled  with  a  viscid 
yellow  fluid,  the  yelk,  containing  numerous  granules.  It  entirely 
fills  the  cavity,  to  the  walls  of  which  it  is  non-adherent.  In  the 
centre  of  the  yelk  in  young,  and  at  some  portion  of  its  periphery  in 
mature  ovules,  is  situated  the  germinal  vesicle,  which  is  a  clear  cir- 
cular vesicle,  refracting  light  strongly,  and  about  8'0th  of  a  line  in 
diameter.  It  contains  a  few  granules,  and  a  nucleolus,  or  germinal 
spot,  which  is  sometimes  double. 

From  within  outwards,  therefore  we  find : — 

1.  The  germinal  spot;  round  this 

2.  The  germinal  vesicle,  contained  in 

3.  The  yelk,  which  is  surrounded  by  the 

•i.  Zona  pellucida,  with  its  layers  of  columnar  epithelial  cells. 

These  constitute  the  ovule. 

The  ovule  is  contained  in — 

The  Graafian  follicle,  and  lies  in  that  part  of  its  epithelial  lining 
called  the — 

Discus  proliferous,  the  rest  of  the  follicle  being  occupied  by  the 
liquor  folliculi.  Bound  these  we  have  the  epithelial  lining  or  ?//'//?- 
brana  yranulosa,  and  the  external  coat  consisting  of  the  tunica  pro- 
pria  and  the  tunica  Jibrosa. 

Vessels  and  Nerves  of  the  Ovary. — The  vascular  supply  of  the  ovary 
is  complex.  The  arteries  enter  at  the  hilum,  penetrating  the  stroma 
in  a  spiral  curve,  and  are  ultimately  distributed  in  a  rich  capillary 


THE  FEMALE  GENERATIVE  ORGANS.  6(J 

plexus  to  the  follicles.  The  large  veins  unite  freely  with  each  other, 
and  form  a  vascular  and  erectile  plexus,  continuous  with  that  sur- 
rounding the  uterus,  called  the  bulb  of  the  ovary  (Fig.  85).  Lym- 
phatics and  nerves  exist,  but  their  mode  of  termination  is  unknown. 

Fui.  35. 


Bull)  of  Ovary. 

u.  Uterus,     o.  Ovary  and  utero-ovarian  ligament,     r.  Fallopian  tube.     1.  Utero-ovarian  vein.     '2. 
I'niiipiuiforiii  ovarian  plexus.     3.  Commencement  of  spermatic  vein. 

The  Mammary  Glands. — To  complete  the  consideration  of  the 
generative  organs  of  the  female  we  must  study  the  mammary  glands, 
which  secrete  the  fluid  destined  to  nourish  the  child.  In  the  human 
subject  they  are  two  in  number,  and  instead  of  being  placed  upon  the 
abdomen,  as  in  most  animals,  they  are  situated  on  either  side  of  the 
sternum,  over  the  pectoralis  major  muscles,  and  extend  from  the  third 
to  the  sixth  ribs.  This  position  of  the  glands  is  obviously  intended 
to  suit  the  erect  position  of  the  female  in  suckling.  They  are  con- 
vex anteriorly,  and  flattened  posteriorly  where  they  rest  on  the 
muscles.  They  vary  greatly  in  size  in  different  subjects,  chiefly  in 
proportion  to  the  amount  of  adipose  tissue  they  contain.  In  man, 
and  in  girls,  previous  to  puberty,  they  are  rudimentary  in  structure ; 
while  in  pregnant  women  they  increase  greatly  in  size,  the  true 
glandular  structures  becoming  much  hypertrophied.  Anomalies  in 
shape  and  position  are  sometimes  observed.  Supplementary  mammae, 
one  or  more  in  number,  situated  on  the  upper  portion  of  the  mam- 
mae, are  sometimes  met  with,  identical  in  structure  with  the  norrnallv 
situated  glands ;  or,  more  commonly,  an  extra  nipple  is  observed  by 
the  side  of  the  normal  one.  In  some  races,  especially  the  African, 
the  mammae  are  so  enormously  developed,  that  the  mother  is  able  to 
suckle  her  child  over  her  shoulder. 

Their  Structure. — The  skin  covering  the  gland  is  soft  and  supple, 
and  during  pregnancy  often  becomes  covered  with  fine  white  lines, 
while  large  blue  veins  may  be  observed  coursing  over.  Underneath. 
it  is  a  quantity  of  connective  tissue,  containing  a  considerable  amount 
of  fat,  which  extends  between  the  true  glandular  structure.  This  is. 
composed  of  from  fifteen  to  twenty  lobes,  each  of  which  is  formed 
of  a  number  of  lobules.  The  lobules  are  produced  by  the  aggrega- 
tion of  the  terminal  acini  in  which  the  milk  is  formed.  The  acini 
are  minute  cul-de-sacs  opening  into  little  ducts,  which  unite  with. 


70  ORGANS    CONCERNED    IN    PARTURITION. 

each  other  until  they  form  a  large  duct  for  each  lobule ;  the  ducts  of 
each  lobule  unite  with  each  other,  until  they  end  in  a  still  larger  duct 
common  to  each  of  the  fifteen  or  twenty  lobes  into  which  the  gland 
is  divided,  and  eventually  open  on  the  surface  of  the  nipple.  These 
terminal  canals  are  known  as  the  yalactophorous  ducts  (Fig.  36). 
They  become  widely  dilated  as  they  approach  the  nipple,  so  as  to 
form  reservoirs  in  which  milk  is  stored  until  it  is  required,  but  when 
they  actually  enter  the  nipple  they  again  contract.  Sometimes  they 
give  off  lateral  branches,  but,  according  to  Sappey,  they  do  not  anas- 
tomose with  each  other,  as  some  anatomists  have  described.  These 
excretory  ducts  are  composed  of  connective  tissue,  with  numerous 
elastic  fibres  on  their  external  surface.  Sappey  and  Eobin  describe 
a  layer  of  muscular  fibres,  chiefly  developed  near  their  terminal 
extremities.  They  are  lined  with  columnar  epithelium,  continuous 
with  that  in  the  acini ;  and  it  is  by  the  distension  of  its  cells  with 
fatty  matter,  and  their  subsequent  bursting,  that  the  milk  is  formed. 
Nipple. — The  nipple  is  the  conical  projection  at  the  summit  of  the 
mamma,  and  it  varies  in  size  in  different  women.  Not  very  unfre- 
quently,  from  the  continuous  pressure  to  which  it  has  been  subjected 
by  the  dress,  it  is  so  depressed  below  the  surface  of  the  skin  as  to 
prevent  lactation.  It  is  generally  larger  in  married  than  in  single 
women,  and  increases  in  size  during  pregnancy.  Its  surface  is  covered 
with  numerous  papillae,  giving  it  a  rugous  aspect,  and  at  their  bases 
the  orifices  of  the  lactiferous  ducts  open.  Here  are  also  the  .openings 
of  numerous  sebaceous  follicles,  which  secrete  an  unctuous  material 
supposed  to  protect  and  soften  the  integument  during  lactation. 
Beneath  the  skin  are  muscular  fibres,  mixed  with  connective  and 

FIG.  36. 


1.  Galactophorous  ducts.  2.  Lobuli  of  the  mammary  gland. 

elastic  tissues,  vessels,  nerves,  and  lymphatics.  When  the  nipple  is 
irritated  it  contracts  and  hardens,  and  by  some  this  is  attributed  to 
its  erectile  properties.  The  vascularity,  however,  is  not  great,  and 
it  contains  no  true  erectile  tissue :  the  hardening  is,  therefore,  due 
to  muscular  contraction.  Surrounding  the  nipple  is  the  areoZa,  of  a 
pink  color  in  virgins,  becoming  dark  from  the  development  of  pig- 
ment cells  during  pregnancy,  and  always  remaining  somewhat  dark 
after  childbearing.  On  its  surface  are  a  number  of  prominent  tuber- 


OVULATION    AND    MENSTRUATION.  71 

cles,  sixteen  to  twenty  in  number,  which  also  become  largely  de- 
veloped during  gestation.  They  are  supposed  by  some  to  secrete 
rnilk,  and  to  open  into  the  lactiferous  tubes;  most  probably  they  are 
composed  of  sebaceous  glands  only.  Beneath  the  areolar  is  a  circular 
band  of  muscular  fibres,  the  object  of  which  is  to  compress  the  lactif- 
erous tubes  which  run  through  it,  and  thus  to  favor  the  expulsion 
of  their  contents.  The  niammne  receive  their  blood  from  the  internal 
mammary  and  intercostal  arteries,  and  they  are  richly  supplied  with 
lymphatic  vessels,  which  open  into  the  axillary  glands.  The  nerves 
are  derived  from  the  intercostal  and  thoracic  branches  of  the  brachial 
plexus. 

The  secretion  of  milk  in  women  who  are  nursing  is  accompanied 
by  a  peculiar  sensation,  as  if  milk  were  rushing  into  the  breast, 
called  the  "draught,"  which  is  excited  by  the  efforts  of  the  child  to 
suck,  and  by  various  other  causes.  The  sympathetic  relations  be- 
tween the  mammse  and  the  uterus  are  very  well  marked,  as  is  shown 
in  the  un impregnated  state  by  the  fact  of  the  frequent  occurrence  of 
sympathetic  pains  in  the  breast  in  connection  with  various  uterine 
diseases,  and,  after  delivery,  by  the  well-known  fact  that  suction  pro- 
duces reflex  contraction  of  the  uterus,  and  even  severe  after-pains. 


CHAPTEE  III. 

OVULATION  AND  MENSTKUATION. 

Functions  of  the  Ovary  .—-The  main  function  of  the  ovary  is  to 
supply  the  female  generative  element,  and  to  expel  it,  when  ready 
for  impregnation,  into  the  Fallopian  tube,  along  which  it  passes  into 
the  uterus.  This  process  takes  place  spontaneously  in  all  viviparous 
animals,  and  without  the  assistance  of  the  male.  In  the  lower  animals 
this  periodical  discharge  receives  the  name  of  the  oestrus  or  rut,  at 
which  time  only  the  female  is  capable  of  impregnation  and  admits 
the  approach  of  the  male.  In  the  human  female  the  periodical  dis- 
charge of  the  ovule,  in  all  probability,  takes  place  in  connection  with 
menstruation,  which  may  therefore  be  considered  to  be  the  analogue 
of  the  rut  in  animals.  After  each  menstrual  period  Graafian  folli- 
cles undergo  changes  which  prepare  them  for  rupture  and  the  dis- 
charge of  their  contained  ovules.  After  rupture,  certain  changes 
occur  which  have  for  their  object  the  healing  of  the  rent  in  the 
ovarian  tissue  through  which  the  ovule  has  escaped,  and  the  filling 
up  of  the  cavity  in  which  it  was  contained.  This  results  in  the  for- 
mation of  a  peculiar  body  in  the  substance  of  the  ovary,  called  the 
corpus  luteum  which  is  essentially  modified  should  pregnancy  occur, 


72  ORGANS    CONCERNED    IN    PARTURITION. 

and  is  of  great  interest  and  importance.  During  the  whole  of  the 
childbearing  epoch  the  periodical  maturation  and  rupture  of  the 
Graafian  follicles  are  going  on.  If  impregnation  does  not  take  place, 
the  ovules  are  discharged  and  lost ;  if  it  does,  ovulation  is  stopped, 
as  a  general  rule,  during  gestation  and  lactation. 

Theory  of  Menstruation. — This,  broadly  speaking,  is  an  outline  of 
the  modern  theory  of  menstruation  which  was  first  broached  in  the 
year  1821  by  Dr.  Power,  and  subsequently  elaborated  by  Negrier, 
Bischoff,  Raciborski,  and  many  other  writers.  Although  the  se- 
quence of  events  here  indicated  may  be  taken  to  be  the  rule,  it  must 
be  remembered  that  it  is  one  subject  to  many  exceptions,  for  un- 
doubtedly ovulation  may  occur  without  its  outward  manifestation, 
menstruation,  as  in  cases  in  which  impregnation  takes  place  during 
lactation  or  before  menstruation  has  been  established,  of  which  many 
examples  are  recorded.  These  exceptions  have  led  some  modern 
writers  to  deny  the  ovular  theory  of  menstruation,  and  their  views 
will  require  subsequent  consideration. 

In  order  to  understand  the  subject  properly  it  will  be  necessary  t<> 
study  the  sequence  of  events  in  detail. 

Changes  in  the  Graafian  Follicle. — The  changes  in  the  Graafian 
follicle  which  are  associated  with  the  discharge  of  the  ovules  com- 
prise— 1.  Maturation.  As  the  period  of  puberty  approaches  a  cer- 
tain number  of  the  Graafian  follicles,  fifteen  to  twenty  in  number, 
increase  in  size,  and  come  near  the  surface  of  the  ovary.  Amongst 
these  one  becomes  especially  developed,  preparatory  to  rupture,  and 
upon  it  for  the  time  being  all  the  vital  energy  of  the  ovary  seems  to 
be  concentrated.  A  similar  change  in  one,  sometimes  in  more  than 
one,  follicle  takes  place  periodically  during  the  whole  of  the  child- 
bearing  epoch,  in  connection  with  each  menstrual  period,  and  an 
examination  of  the  ovary  will  show  several  follicles  in  different  stages 
of  development.  The  maturing  follicle  becomes  gradually  larger, 
until  it  forms  a  projection  on  the  surface  of  the  ovary,  from  five  to 
seven  lines  in  breadth,  but  sometimes  even  as  large  as  a  nut  (Fig. 
30).  This  growth  is  due  to  the  distension  of  the  follicle  by  the  in- 
crease of  its  contained  fluid,  which  causes  it  so  to  press  upon  the 
ovarian  structures  covering  it,  that  they  become  thinned,  separated 
from  each  other,  and  partially  absorbed,  until  they  eventually  readilv 
lacerate.  The  follicle  also  becomes  greatly  congested,  the  capillaries 
coursing  over  it  becomes  increased  in  size  and  loaded  with  blood, 
and  being  seen  through  the  attenuated  ovarian  tissue,  give  it,  when 
mature,  a  bright  red  color.  At  this  time  some  of  these  distended 
capillaries  in  its  inner  coat  lacerate,  and  a  certain  quantity  of  blood 
escapes  into  its  cavity.  This  escape  of  blood  takes  place  before 
rupture,  and  seems  to  have  for  its  principal  object  the  increase  of  the 
tension  of  the  follicle,  of  which  it  has  been  termed  the  menstruation. 
Pouchet  was  of  opinion  that  the  blood  collects  behind  the  ovule,  and 
carries  it  up  to  the  surface  of  the  follicle.  By  these  means  the  follicle 
is  more  and  more  distended,  until  at  last  it  ruptures  either  sponta- 
neously or,  it  may  be,  under  the  stimulus  of  sexual  excitement. 
Whether  the  laceration  takes  place  during,  before,  or  after  the  men- 


OVULATION  AND  MENSTRUATION.  73 

strual  discharge  is  not  yet  positively  known :  from  the  results  of 
post-mortern  examination  in  a  number  of  women  who  died  shortly 
before  or  after  the  period,  Williams  believes  that  the  ovules  are  ex- 
pelled before  the  monthly  flow  commences.1  In  order  that  the  ovule 
may  escape,  the  laceration  must,  of  course,  involve  not  only  the  coats 
of  the  Graafian  follicles,  but  also  the  superincumbent  structures. 

Laceration  seems  to  be  aided  by  the  growth  of  the  internal  layer 
of  the  follicle,  which  increases  in  thickness  before  rupture,  and 
assumes  a  characteristic  yellow  color  from  the  number  of  oil-globules 
it  then  contains.  It  is  also  greatly  facilitated,  if  it  be  not  actually 
produced,  by  the  turgescence  of  the  ovary  at  each  menstrual  period, 
and  by  the  contraction  of  the  muscular  fibres  in  the  ovarian  stroma. 
As  soon  as  the  rent  in  the-follicular  walls  is  produced,  the  ovule  is 
discharged,  surrounded  by  some  of  the  cells  of  the  meinbrana  granu- 
losa,  and  is  received  into  the  fimbriated  extremity  of  the  Fallopian 
tube,  which  grasps  the  ovary  over  the  site  of  the  rupture.  By  the 
vibratile  cilia  of  its  epithelial  lining,  it  is  then  conducted  into  the 
canal  of  the  tube,  along  which  it  is  propelled,  partly  by  ciliary  action 
and  partly  by  muscular  contraction  in  the  walls  of  the  tube. 

Obliteration  of  the  Graafian  Follicle. — After  the  ovule  has  escaped, 
certain  characteristic  changes  occur  in  the  empty  Graafian  follicle, 
which  have  for  their  object  its  cicatrization  and  obliteration.  There 
are  great  differences  in  the  changes  which  occur  when  impregnation 
has  followed  the  escape  of  the  ovule,  and  they  are  then  so  remarkable 
that  they  have  been  considered  certain  signs  of  pregnancy.  They 
are,  however,  differences  of  degree  rather  than  of  kind.  It  will  be 
well,  however,  to  discuss  them  separately. 

Changes  undergone  by  the  Follicle  where  Impregnation  does  not  occur. 
— As  soon  as  the  ovule  is  discharged,  the  edges  of  the  rent  through 
\vhich  it  has  escaped  become  agglutinated  by  exudation,  and  the  fol- 
licle shrinks,  as  is  generally  believed,  by  the  inherent  elasticity  of  its 
internal  coat,  but  according  to  Eobin,  who  denies  the  existence  of 
this  coat,  from  compression  by  the  muscular  fibres  of  the  ovarian 
stroma.  In  proportion  to  the  contraction  that  takes  place,  the  inner 
layer  of  the  follicle,  the  cells  of  which  have  become  greatly  hyper- 
trophied  and  loaded  with  fat  granules  previous  to  rupture,  is  thrown 
into  numerous  folds.  The  greater  the  amount  of  contraction  the 
deeper  these  folds  become,  giving  to  a  section  of  the  follicle  an 
appearance  similar  to  that  of  the  convolutions  of  the  brain  (Fig.  37). 
These  folds  in  the  human  subject  are  generally  of  a  bright  yellow 
color,  but  in  some  of  the  mammalia  they  are  of  a  deep  red.  The  tint 
was  formerly  ascribed  by  Eaciborski  to  absorption  of  the  coloring 
matter  of  the  blood-clot  contained  in  the  follicular  cavity,  a  theory 
he  has  more  recently  abandoned  in  favor  of  the  view  maintained 
by  Coste  that  it  is  due  to  the  inherent  color  of  the  cells  of  the  lining 
membrane  of  the  follicle,  which,  though  not  well  marked  in  a  single 
cell,  becomes  very  apparent  en  masse.  The  existence  of  a  contained 
blood-clot  is  also  denied  by  the  latter  physiologist,  except  as  an 

1  Proceedings  of  the  Royal  Society,  1875. 


ORGANS    CONCERNED    IN    PARTURITION. 


Section  of  ovary,  showing  corpus  lute- 

um  three  weeks  after  menstruation. 

(After  Dalton.) 


unusual  pathological  condition  ;  and  he  describes  the  cavity  as  contain- 
ing a  gelatinous  and  plastic  fluid,  which  becomes  absorbed  as  contrac- 
tion advances.  The  folds  into  which  the  membrane  has  been  thrown 

continue  to  increase  in  size,  from  the 
proliferation  of  their  cells,  until  they 
unite  and  become  adherent,  and  eventu- 
ally fill  the  follicular  cavity.  By  the 
time  that  another  Graafian  follicle  is 
matured  and  ready  for  rupture  the 
diminution  has  advanced  considerably, 
and  the  empty  ovisac  is  reduced  to  a 
very  small  size.  The  cavity  is  now 
nearly  obliterated,  the  yellow  color  of 
the  convolutions  is  altered  into  a  whitish 
tint,  and  on  section  the  corpus  luteum 
has  the  appearance  of  a  compact  white 
stellate  cicatrix,  which  generally  disap- 
pears in  less  than  forty  days  from  the 
period  of  rupture.  The  tissue  of  the 
ovary  at  the  site  of  laceration  also 
shrinks,  and  this,  aided  by  the  contrac- 
tion of  the  follicle,  gives  rise  to  one  of  those  permanent  pits  or 
depressions  which  mark  the  surface  of  the  adult  ovary.  Slavy- 
ansky1  has  recently  shown  that  only  a  few  of  the  immense  number 
of  Graafian  follicles  undergo  these  alterations.  The  greater  propor- 
tion of  them  seem  never  to  discharge  their  ovules,  but,  after  increas- 
ing in  size,  undergo  retrogressive  changes  exactly  similar  in  their 
nature,  but  to  a  much  less  extent,  to  those  which  result  in  the  for- 
mation of  a  corpus  luteum.  The  sites  of  these  may  afterwards  be 
seen  as  minute  striae  in  the  substance  of  the  ovary. 

Changes  undergone  by  the  Follicle  when  Impregnation  has  taken 
place. — Should  pregnancy  occur,  all  the  changes  above  described  take 
place,  but,  inasmuch  as  the  ovary  partakes  of  the  stimulus  to  which 
all  the  generative  organs  are  then  subjected,  they  are  much  more 
marked  and  apparent.  Instead  of  contracting  and  disappearing  in  a 
few  weeks,  the  corpus  luteum  continues  to  grow  until  the  third  or 
fourth  month  of  pregnancy ;  the  folds  of  the  inner  layer  of  the  ovisac 
become  large  and  fleshy,  and  permeated  by  numerous  capillaries,  and 
ultimately  become  so  firmly  united  that  the  margins  of  the  convolu- 
tions thin  and  disappear,  leaving  only  a  firm  fleshy  yellow  mass, 
averaging  from  1  to  1 J  inches  in  thickness,  which  surrounds  a  central 
cavity,  often  containing  a  whitish  fibrillated  structure,  believed  to 
be  the  remains  of  a  central  blood  clot.  This  was  erroneously  sup- 
posed by  Montgomery  to  be  the  inner  layer  of  the  follicle  itself,  and 
he  conceived  the  yellow  substance  to  be  a  new  formation  between  it 
and  the  external  layer,  while  Robert  Lee  thought  it  was  placed 
external  to  both  the  external  and  internal  layers. 

Between  the  third  and  fourth  months  of  pregnancy,  when  the 


1  Archiv  de  Phys.  March,  1874. 


OVULATION    AND    MENSTRUATION.  75 

corpus  luteum  has  attained  its  maximum  of  development  (Fig.  38), 
it  forms  a  firm  projection  on  the  surface  of  the  ovary,  averaging 
about  1  inch  in  length,  and  rather  more  than  J  an  inch  in  breadth; 
After  this  it  commences  to  atrophy  (Fig.  39),  the  fat-cells  become 

FIG.  38.  FIG.  39. 


Corpus  luteum  at  the  fourth  month  of  pregnancy.  Corpus  luteum  of  pregnancy  at 

(After  Dalton.)  term.     (After  Dalton.) 

absorbed,  and  the  capillaries  disappear.  Cicatrization  is  not  com- 
plete until  from  one  to  two  months  after  delivery. 

Its  Value  as  a  Sign  of  Pregnancy. — On  account  of  the  marked 
appearance  of  the  corpus  luteurn  it  was  formerly  considered  to  be  an 
infallible  sign  of  pregnancy ;  and  it  was  distinguished  from  the  cor- 
pus luteum  of  the  nonpregnant  state  by  being  called  a  "  true"  as 
opposed  to  a  "false"  corpus  luteum.  From  what  has  been  said  it 
will  be  obvious  that  this  designation  is  essentially  wrong,  as  the 
difference  is  one  of  degree  only.  Nor  do  obstetricians  attach  by  any 
means  the  same  importance  as  they  did  formerly  to  its  presence  as 
indicating  impregnation ;  for  even  when  well  marked,  other  and 
more  reliable  signs  of  recent  delivery,  such  as  enlargement  of  the 
uterus,  are  sure  to  be  present,  especially  at  the  time  when  it  has 
reached  its  maximum  of  development ;  while  after  delivery  at  term 
it  has  no  longer  a  sufficiently  characteristic  appearance  to  be  depended 
on. 

Menstruation. — By  the  term  menstruation  (catamenia,  periods,  etc.), 
is  meant  the  periodical  discharge  of  blood  from  the  uterus,  which 
occurs,  in  the  healthy  woman,  every  lunar  month,  except  during 
pregnancy  and  lactation,  when  it  is,  as  a  rule,  suspended. 

Period  of  Establishment. — The  first  appearance  of  menstruation 
coincides  with  the  establishment  of  puberty,  and  the  physical  changes 
that  accompany  it  indicate  that  the  female  is  capable  of  conception 
and  childbearing,  although  exceptional  cases  are  recorded  in  which 
pregnancy  occurred  before  menstruation  had  begun.  In  temperate 
climates  it  generally  commences  between  the  14th  and  16th  years, 
the  largest  number  of  cases  being  met  with  in  the  15th  year.  This 


76  ORGANS    CONCERNED    IN    PARTURITION. 

rule  is  subject  to  many  exceptions,  it  being  by  no  means  very  rare 
for  menstruation  to  become  established  as  early  as  the  10th  or  llth 
years,  or  to  be  delayed  until  the  18th  or  20th.  Beyond  these  physio- 
logical limits  a  few  cases  are  from  time  to  time  met  with  in  which  it 
has  begun  in  early  infancy,  or  not  until  a  comparatively  late  period 
of  life. 

Influence  of  Climate,  Race,  etc. — Various  accidental  circumstances 
have  much  to  do  with  its  establishment.  As  a  rule,  it  occurs  some- 
what earlier  in  tropical,  and  later  in  very  cold,  than  in  temperate  cli- 
mates. The  influence  of  climate  has  been  unduly  exaggerated.  It 
used  to  be  generally  stated  that  in  the  Arctic  regions  women  did  not 
menstruate  until  they  were  of  mature  age,  and  that  in  the  tropics 
girls  of  10  or  12  years  of  age  did  so  habitually.  The  researches  of 
Roberton,  of  Manchester,1  lirst  showed  that  the  generally  received 
opinions  were  erroneous ;  and  the  collection  of  a  large  number  of 
statistics  has  corroborated  his  opinion.  There  can  be  no  doubt,  how- 
ever, that  a  larger  proportion  of  girls  menstruate  early  in  warm  cli- 
mates. Joulin  found  that  in  tropical  climates,  out  of  1635  cases,  the 
largest  proportion  began  to  menstruate  between  the  12th  and  13th 
years ;  so  that  there  is  an  average  difference  of  more  than  two  years 
between  the  period  of  its  establishment  in  the  tropics  and  in  temper- 
ate countries.  Harris2  states  that  among  the  Hindoos  1  to  2  per  cent, 
menstruate  as  early  as  nine  years  of  age ;  3  to  4  per  cent,  at  ten ;  8 
per  cent,  at  eleven  ;  and  25  per  cent,  at  twelve ;  while  in  London  or 
Paris  probably  not  more  than  one  girl  in  1000  or  1200  does  so  at 
nine  years.  The  converse  holds  true  with  regard  to  cold  climates, 
although  we  are  not  in  possession  of  a  sufficient  number  of  accurate 
statistics  to  draw  very  reliable  conclusions  on  this  point ;  but  out  of 
4715  cases, -including  returns  from  Denmark,  Norway  and  Sweden,  Rus- 
sia and  Labrador,  it  was  found  that  menstruation  was  established  on 
an  average  a  year  later  than  in  more  temperate  countries.  It  is  prob- 
able that  the  mere  influence  of  temperature  has  much  to  do  in  produc- 
ing these  differences,  but  there  are  other  factors,  the  action  of  which 
must  not  be  overlooked.  Raciborski  attributes  considerable  import- 
ance to  the  effect  of  race ;  and  he  has  quoted  Dr.  Webb,  of  Calcutta, 
to  the  effect  that  English  girls  in  India,  although  subjected  to  the 
same  climatic  influence  as  the  Indian  races,  do  not,  as  a  rule,  men- 
struate earlier  than  in  England ;  while  in  Austria,  girls  of  the  Magyar 
race  menstruate  considerably  later  than  those  of  German  parentage.3 
The  surroundings  of  girls,  and  their  manner  of  education  and  living, 
have  probably  also  a  marked  influence  in  promoting  or  retarding  its 
establishment.  Thus,  it  will  commence  earlier  in  the  children  of  the 
rich,  who  are  likely  to  have  a  highly  developed  nervous  organization, 
and  are  habituated  to  luxurious  living,  and  a  premature  stimulation 
of  the  mental  faculties  by  novel-reading,  society,  and  the  like  ;  while 
amongst  the  hard-worked  poor,  or  in  girls  brought  up  in  the  country, 

1  Edin.  Med.  and  Surg.  Journ.,  1832. 

2  Amer.  Journ.  of  Obst.  1871.     R.  P.  Harris,  on  early  puberty. 

3  Op.  fit.,  p.  227- 


OVULATION    AND    MENSTRUATION.  77 

it  is  more  likely  to  begin  later.  Premature  sexual  excitement  is  said 
also  to  favor  its  early  appearance,  and  the  influence  of  this  among 
the  factory  girls  of  Manchester,  who  are  exposed  in  the  course  of 
their  work  to  the  temptations  arising  from  the  promiscuous  mixing 
of  the  sexes,  has  been  pointed  out  by  Dr.  Clay.1 

Changes  Occurring  at  Puberty. — The  first  appearance  of  menstrua- 
tion is  accompanied  by  certain  well-marked  changes  in  the  female 
system,  on  the  occurrence  of  which  we  say  that  the  girl  has  arrived 
at  the  period  of  puberty.  The  pubes  become  covered  with  hair,  the 
breasts  enlarge,  the  pelvis  assumes  its  fully-developed  form,  and  the 
general  contour  of  the  body  fills  out.  The  mental  qualities  also  alter ; 
the  girl  becomes  more  shy  and  retiring,  and  her  whole  bearing  indi- 
cates the  change  that  has  taken  place.  The  menstrual  discharge  is 
not  established  regularly  at  once.  For  one  or  two  months  there  may 
be  only  premonitory  symptoms :  a  vague  sense  of  discomfort,  pains 
in  the  breasts,  and  a  feeling  of  weight  and  heat  in  the  back  and  loins. 
There  then  may  be  a  discharge  of  mucus  tinged  with  blood,  or  of 
pure  blood,  and  this  may  not  again  show  itself  for  several  months. 
Such  irregularities  are  of  little  consequence  on  the  first  establishment 
of  the  function,  and  need  give  rise  to  no  apprehension. 

Period  of  Duration  and  Recurrence. — As  a  rule,  the  discharge  re- 
curs every  twenty -eight  days,  and  with  some  women  with  such  regu- 
larity that  they  can  foretell  its  appearance  almost  to  the  hour.  The 
rule  is,  however,  subject  to  very  great  variations.  It  is  by  no  means 
uncommon,  and  strictly  within  the  limits  of  health,  for  it  to  appear 
every  twentieth  day,  or  even  with  less  interval ;  while,  in  other  cases, 
as  much  as  six  weeks  may  habitually  intervene  between  two  periods. 
The  period  of  recurrence  may  also  vary  in  the  same  subject.  I  am 
acquainted  with  patients  who  sometimes  have  only  twenty-eight  days, 
at  others  as  many  as  forty-eight  days,  between  their  periods,  without 
their  health  in  any  way  suffering.  Joulin  mentions  the  case  of  a  lady 
who  only  menstruated  two  or  three  times  in  the  year,  and  whose 
sister  had  the  same  peculiarity. 

The  duration  of  the  period  varies  in  different  women,  and  in  the 
same  woman  at  different  times.  In  this  country  its  average  Is  four 
or  five  days,  while  in  France  Dubois  and  Brierre  de  Boismont  fix 
eight  days  as  the  most  usual  length.  Some  women  are  only  unwell 
for  a  few  hours,  while  in  others  the  period  may  last  many  days 
beyond  the  average  without  being  considered  abnormal. 

Quantity  of  Blood  lost. — The  quantity  of  blood  lost  varies  in  dif- 
ferent women.  Hippocrates  puts  it  at  Jxviij,  which,  however,  is 
much  too  high  an  estimate.  Arthur  Farre  thinks  that  from  3ij  to 
iiij  is  the  full  amount  of  a  healthy  period,  and  that  the  quantity 
cannot  habitually  exceed  this  without  producing  serious  constitu- 
tional effects.  Kich  diet,  luxurious  living,  and  anything  that  un- 
healthily stimulates  the  body  and  mind,  will  have  an  injurious  effect 
in  increasing  the  flow,  which  is,  therefore,  less  in  hard-worked 
countrywomen  than  in  the  better  classes  and  residents  in  towns. 

1  Brit.  Record  of  Obst.  Med.,  vol.  i. 


78  ORGANS    CONCERNED    IX    PARTURITION. 

It  is  more  abundant  in  warm  climates,  and  our  countrywomen  in 
India  habitually  menstruate  over-profusely,  becoming  less  abundantly 
unwell  when  they  return  to  England.  [The  same  may  be  said  of  our 
Northern  women  when  residing  in  the  Gulf  States,  and  of  many  natives 
of  those  States,  who  improve  materially  by  removing  to  the  Lake 
States. — ED.]  Some  women  appear  to  menstruate  more  in  summer 
than  in  winter.  I  am  acquainted  with  a  lady  who  spends  the  winter 
in  St.  Petersburg,  where  her  periods  last  eight  or  ten  days,  and  the 
summer  in  England,  where  they  never  exceed  four  or  five.  The 
difference  is  probabty  due  to  the  effect  of  the  over-heated  rooms  in 
which  she  lives  in  Eussia. 

The  daily  loss  is  not  the  same  during  the  continuance  of  the  period. 
It  generally  is  at  first  slight,  and  gradually  increases  so  as  to  be  most 
profuse  on  the  second  or  third  day,  and  as  gradually  diminishes.  To- 
wards the  last  days  it  sometimes  disappears  for  a  few  hours,  and 
then  comes  on  again,  and  is  apt  to  recur  under  any  excitement  or 
emotion. 

Quality  of  Menstrual  Blood. — As  the  menstrual  fluid  escapes  from 
the  uterus  it  consists  of  pure  blood,  and,  if  collected  through  the 
speculum,  it  coagulates.  The  ordinary  menstrual  fluid  does  not 
coagulate  unless  it  is  excessive  in  amount.  Various  explanations  of 
this  fact  have  been  given.  It  was  formerly  supposed  either  to  contain 
no  fibrine,  or  an  unusually  small  amount.  Retzius  attributes  its 
non-coagulation  to  the  presence  of  free  lactic  and  phosphoric  acids. 
The  true  explanation  was  first  given  by  Mandl,  who  proved  that 
even  small  quantities  of  pus  or  mucus  in  blood  were  sufficient  to 
keep  the  fibrine  in  solution;  and  mucus  is  always  present  to  greater 
or  less  amount  in  the  secretions  of  the  cervix  and  vagina,  which  mix 
with  the  menstrual  blood  in  its  passage  through  the  genital  tract. 
If  the  amount  of  blood  be  excessive,  however,  the  mucus  present  is 
insufficient  in  quantity  to  produce  this  effect,  and  coagula  are  then 
formed. 

On  microscopic  examination  the  menstrual  fluid  exhibits  blood 
corpuscles,  mucous  corpuscles,  and  a  considerable  amount  of  epithelial 
scales,  the  last  being  the  debris  of  the  epithelium  lining  the  uterine 
cavity.  According  to  Virchow  the  form  of  the  epithelium  often 
proves  that  it  comes  from  the  interior  of  the  utricular  glands.  The 
color  of  the  blood  is  at  first  dark,  and  as  the  period  progresses  it 
generally  becomes  lighter  in  tint.  In  women  who  are  in  bad  health 
it  is  often  very  pale.  These  differences  doubtless  depend  upon  the 
amount  of  mucus  mingled  with  it.  The  menstrual  blood  has  always 
a  characteristic,  faint,  and  heavy  odor,  which  is  analogous  to  that 
which  is  so  distinct  in  the  lower  animals  during  the  rut.  Raciborski 
mentions  a  lady  who  was  so  sensitive  to  this  odor  that  she  could 
always  tell  to  a  certainty  when  any  woman  was  menstruating.  It 
is  attributed  either  to  decomposing  mucus  mixed  with  the  blood, 
which,  when  partially  absorbed,  may  cause  the  peculiar  odor  of  the 
breath  often  perceptible  in  menstruating  women;  or  to  the  mixture 
with  the  fluid  of  the  sebaceous  secretion  from  the  glands  of  the  vulva. 
It  probably  gave  rise  to  the  old  and  prevalent  prejudices  as  to  the 


OVULATION    AND    MENSTRUATION.  7U 

deleterious  properties  of  menstrual  blood,  which,  it  is  needless  to  say, 
are  altogether  without  foundation. 

Source  of  the  Blood. — It  is  now  universally  admitted  that  the  source 
of  the  menstrual  blood  is  the  mucous  membrane  lining  the  interior 
of  the  uterus,  for  the  blood  may  be  seen  oozing  through  the  os  uteri 
by  means  of  the  speculum,  and  in  cases  of  prolapsus  uteri ;  while  in 
cases  of  inverted  uterus  it  may  be  actually  observed  escaping  from 
the  exposed  mucous  membrane,  and  collecting  in  minute  drops  upon 
its  surface.  During  the  menstrual  nisus  the  whole  mucous  lining 
becomes  congested  to  such  an  extent  that,  in  examining  the  bodies 
of  women  who  have  died  during  menstruation,  it  is  found  to  be 
thicker,  larger,  and  thrown  into  folds,  so  as  to  completely  fill  the 
uterine  cavity.  The  capillary  circulation  at  this  time  becomes  very 
marked,  and  the  mucous  membrane  assumes  a  deep  red  hue,  the  net- 
work of  capillaries  surrounding  the  orifices  of  the  utricular  glands 
being  especially  distinct.  These  facts  have  an  unquestionable  con- 
nection with  the  production  of  the  discharge,  but  there  is  much  diffe- 
rence of  opinion  as  to  the  precise  mode  in  which  the  blood  escapes 
from  the  vessels.  Coste  believed  that  the  blood  transudes  through 
the  coats  of  the  capillaries  without  any  laceration  of  their  structure. 
Farre  inclines  to  the  hypothesis  that  the  uterine  capillaries  terminate 
by  open  mouths,  the  escape  of  blood  through  these,  between  the 
menstrual  periods,  being  prevented  by  muscular  contraction  of  the 
uterine  walls.  Pouchet  believed  that  during  each  menstrual  epoch 
the  entire  mucous  membrane  is  broken  down  and  cast  off  in  the  form 
of  minute  shreds,  a  fresh  mucous  membrane  being  developed  in  the 
interval  between  two  periods.  During  this  process  the  capillary  net- 
work would  be  laid  bare  and  ruptured,  and  the  escape  of  blood 
readily  accounted  for.  Tyler  Smith,  who  adopted  this  theory,  states 
that  he  has  frequently  seen  the  uterine  mucous  membrane,  in  women 
who  have  died  during  menstruation,  in  a  state  of  dissolution,  with 
the  broken  loops  of  the  capillaries  exposed.  The  phenomena  at- 
tending the  so-called  membranous  dysmenorrhcea,  in  which  the 
rnucous  membrane  is  thrown  off'  in  shreds,  or  as  a  cast  of  the  uterine 
cavity — the  nature  of  which  was  first  pointed  out  by  Simpson  and 
Oldham — have  been  supposed  to  corroborate  this  theory.  This  view 
is,  in  the  main,  corroborated  by  the  recent  researches  of  Engelman, 
Williams,1  and  others.  Williams  describes  the  mucous  lining  of  the 
uterus  as  undergoing  a  fatty  degeneration  before  each  period,  which 
commences  near  the  inner  os,  and  extends  over  the  whole  mucous 
membrane,  and  down  to  the  muscular  wall.  This  seems  to  bring  on 
a  certain  amount  of  muscular  contraction,  which  drives  the  blood 
into  the  capillaries  of  the  mucosa,  and  these,  having  become  degene- 
rated, readily  rupture,  and  permit  the  escape  of  the  blood.  The 
mucous  membrane  now  rapidly  disintegrates,  and  is  cast  off  in  shreds 
with  the  menstrual  discharge,  in  which  masses  of  epithelial  cells  may 
always  be  detected.  As  soon  as  the  period  is  over  the  formation  of 
a  new  mucous  membrane  is  begun,  from  proliferation  of  the  elements 

1  On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,  Obst.  Journ.,  1875. 


80  ORGANS    CONCERNED    IN    PARTURITION. 

of  the  muscular  coat,  and  at  the  end  of  a  week  the  whole  uterine 
cavity  is  lined  by  a  thin  mucous  membrane.  This  grows  until  the 
advent  of  another  period,  when  the  same  degenerative  changes  occur 
unless  impregnation  has  taken  place,  in  which  case  it  becomes  further 
developed  into  the  decidua. 

Theory  of  Menstruation. — That  there  is  an  intimate  connection  be- 
tween ovulation  and  menstruation  is  admitted  by  most  physiologists, 
and  it  is  held  by  many  that  the  determining  cause  of  the  discharge 
is  the  periodic  maturation  of  the  Graafian  follicles.  There  is  abundant 
evidence  of  this  connection,  for  we  know  that  when,  at  the  change 
of  life,  the  Graafian  follicles  cease  to  develop,  menstruation  is  arrested; 
and  when  the  ovaries  are  removed  by  operation,  of  which  there  are 
now  numerous  cases  on  record,  or  when  they  are  congenitally  absent, 
menstruation  does  not  take  place.  A  few  cases,  however,  have  been 
observed  in  which  menstruation  continued  after  double  ovariotomy, 
and  these  have  been  used  as  an  argument  by  those  physiologists  who 
doubt  the  ovular  theory  of  menstruation.  Slavyansky  has  particu- 
larly insisted  on  such  cases,  which,  however,  are  probably  susceptible 
of  explanation.  It  may  be  that  the  habit  of  menstruation  may  con- 
tinue for  a  time  even  after  the  removal  of  the  ovaries,  and  it  has  not 
been  shown  that  menstruation  has  continued  permanently  after  double 
ovariotomy,  although  it  certainly  has  occasionally,  although  quite 
exceptionally,  done  so  for  a  time.  It  is  possible,  also,  that,  in  such 
cases,  a  small  portion  of  ovarian  tissue  may  have  been  left  unre- 
moved,  sufficient  to  carry  on  ovulation.  Roberts,  a  traveller  quoted 
bv  Depaul  and  Gueniot  in  their  article  on  Menstruation  in  the  "Dic- 
tionnaire  des  Sciences  MeMicales,"  relates  that  in  certain  parts  of 
Central  Asia  it  is  the  custom  to  remove  both  ovaries  in  young  girls 
who  act  as  guards  to  the  harems.  These  women,  known  as  hedjeras, 
subsequently  assume  much  of  the  virile  type,  and  never  menstruate. 
The  same  close  connection  between  ovulation  and  the  rut  of  animals 
is  observed,  and  supports  the  conclusion  that  the  rut  and  menstrua- 
tion are  analogous.  The  chief  difference  between  ovulation  in  man 
and  the  lower  animals  is  that  in  the  latter  the  process  is  not  generally 
accompanied  by  a  sanguineous  flow.  To  this  there  are  exceptions, 
for  in  monkeys  there  is  certainly  a  discharge  analogous  to  menstrua- 
tion occurring  at  intervals.  Another  point  of  distinction  is  that  in 
animals  connection  never  takes  place  except  during  the  rut,  and  that 
it  is  then  only  that  the  female  is  capable  of  conception ;  while  in 
the  human  race  conception  only  occurs  in  the  interval  between  the 
periods.  This  is  another  argument  brought  against  the  ovular  theory, 
because,  it  is  said,  if  menstruation  depend  on  the  rupture  of  a.  Graafian 
follicle  and  the  emission  of  an  ovule,  then  impregnation  should  only 
take  place  during  or  immediately  after  menstruation.  Coste  explains 
this  by  supposing  that  it  is  the  maturation  and  not  the  rupture  of  the 
follicle  which  determines  the  occurrence  of  menstruation ;  and  that 
the  follicle  may  remain  unruptured  for  a  considerable  time  after  it  is 
mature,  the  escape  of  the  ovule  being  subsequently  determined  by 
some  accidental  cause,  such  as  sexual  excitement.  However  this 
may  be,  there  is  good  reason  to  believe  that  the  susceptibility  to  con- 


OVULATION    AND    MENSTRUATION.  81 

ception  is  greater  during  the  menstrual  epochs.  Raciborski  believes 
that  in  the  large  proportion  of  cases  impregnation  occurs  in  the  first 
half  of  the  menstrual  interval,  or  in  the  few  days  immediately  pre- 
ceding the  appearance  of  the  discharge.  There  are,  however,  very 
numerous  exceptions,  for  in  Jewesses,  who  almost  invariably  live 
apart  from  their  husbands  for  eight  days  after  the  cessation  of  men- 
struation, impregnation  must  constantly  occur  at  some  other  period 
of  the  interval,  and  it  is  certain  that  they  are  not  less  prolific  than 
other  people.  This  rule  with  them  is  very  strictly  adhered  to,  as 
will  be  seen  by  the  accompanying  interesting  letter  from  a  medical 
friend  who  is  a  well-known  member  of  that  community,  and  which 
I  have  permission  to  publish.1  This  fact  is  of  itself  sufficient  to 
disprove  the  theory  advanced  by  Dr.  Avrard,2  that  impregnation  is 
impossible  in  the  latter  half  of  the  menstrual  interval.  This,  and 
the  other  reasons  referred  to,  undoubtedly  throw  some  doubt  on  the 
ovular  theory,  but  they  do  not  seem  to  be  sufficient  to  justify  the 
conclusion  that  menstruation  is  a  physiological  process  altogether 
independent  of  the  development  and  maturation  of  the  Graafian 
follicles.  All  that  they  can  be  fairly  held  to  prove  is  that  the  escape 
of  the  ovules  may  occur  independently  of  menstruation,  but  the 
weight  of  evidence  remains  strongly  in  favor  of  the  theory  which  is 
generally  received. 

1  10  Bernard  Street,  Russell  Square,  July  28, 1873. 
MY  DKAU  SIR. 

1.  To  the  best  of  my  knowledge  and  belief,  the  law  which  prohibits  sexual 
intercourse  amongst  Jews  for  seven  clear  days  after  the  cessation  of  menstruation,  is 
almost  universally  observed ;  the  exceptions  not  being  sufficient  to  vitiate  statistics. 
The  law  has  perhaps  fewer  exceptions  on  the  Continent — especially  Russia  and 
Poland,  where  the  Jewish  population  is  very  great — than  in  England.  Even  here, 
however,  women  who  observe  no  other  ceremonial  law  observe  this,  and  cling  to  it 
after  everything  else  is  thrown  overboard.  There  are  doubtless  many  exceptions, 
especially  among  the  better  classes  in  England,  who  keep  only  three  days  after  the 
cessation  of  the  menses. 

2.  The  law  is — as  you  state — that  should  the  discharge  last  only  an  hour  or  so,  or 
should  there  be  only  one  gush  or  one  spot  on  the  linen,  the  five  days  during  which 
the  period  might  continue  are  observed  ;  to  which  must  be  superadded  the  seven  clear 
days  =  twelve  days  per  mensem  in  which  connection  is  disallowed.     Should  any  dis- 
charge be  seen  in  the  intermenstrual  period,  seven  days  would  have  to  be  kept,  but 
not  the  five,  for  such  irregular  discharge. 

3.  The  "bath  of  purification,"  which  must  contain  at  least  eighty  gallons,  is  used 
on  the  last  night  of  the  seven  clear  days.     It  is  not  used  till  after  a  bath  for  cleansing 
purposes;  and,  from  the  night  when  such  "purifying"  bath  is  used,  Jewish  women 
are  accustomed  to  calculate  the  commencement  of  pregnancy.     That  you  should  not 
have  heard  of  it  is  not  strange  ;  its  mention  would  be  considered  highly  indelicate. 

4.  Jewish  women  reckon  their  pregnancy  to  last  nine  calendar  or  ten  lunar  months, 
270  to  280  days.     There  are  no  special  data  on  which  to  reckon  an  average,  nor  do 
I  know  of  any  books  on  the  subject,  except  some  Talmudic  authorities  which  I  will 
look  up  for  you  if  you  desire  it.     Pray  make  no  apologies  for  writing  to  me ;  any 
information  I  possess  is  at  your  service. 

I  am,  dear  Sir,  yours  very  truly, 

Dr.  Playfair.  A.  ASHER. 

P.S.  The  Biblical  foundation  for  the  law  of  the  seven  clear  days  is  Leviticus  xv., 
verse  19  till  the  end  of  the  chapter — especially  verse  28. 

2  Rev.  de  ThSrap.  Med.  Chir.  1867. 


82  ORGANS    CONCERNED    IN    PARTURITION. 

Purpose  of  the.  Menstrual  Loss. — The  cause  of  the  monthly  perio- 
dicity is  quite  unknown,  and  will  probably  always  remain  so.  The 
purpose  of  the  loss  of  so  much  blood  is  also  somewhat  obscure.  To 
a  certain  extent  it  must  be  considered  an  accident  or  complication 
of  ovulation,  produced  by  the  vascular  turgescence.  Nor  is  it  essen- 
tial to  fecundation,  because  women  often  conceive  during  lactation, 
when  menstruation  is  suspended;  or  before  the  function  has  become 
established.  It  may,  however,  serve  the  negative  purpose  of  relieving 
the  congested  uterine  capillaries  which  are  periodically  filled  with  a 
supply  of  blood  for  the  great  growth  which  takes  place  when  concep- 
tion has  occurred.  Thus  immediately  before  each  period  the  uterus 
may  be  considered  to  be  placed  by  the  afflux  of  blood  in  a  state  of 
preparation  for  the  function  it  may  be  suddenly  called  upon  to  per- 
form. That  the  discharge  relieves  a  state  of  vascular  tension  which 
accompanies  ovulation  is  proved  by  the  singular  phenomenon  of 
vicarious  menstruation,  which  is  occasionally,  though  rarely,  met 
with.  It  occurs  in  cases  in  which,  from  some  unexplained  cause, 
the  discharge  does  not  escape  from  the  uterine  mucous  membrane. 
Under  such  circumstances  a  more  or  less  regular  escape  of  blood  may 
take  place  from  other  sites.  The  most  common  situations  are  the 
mucous  membranes  of  the  stomach,  of  the  nasal  cavities,  or  of  the 
lungs;  the  skin,  not  uncommonly  that  of  the  mammae,  probably  on 
account  of  their  intimate  sympathetic  relation  with  the  uterine  organs; 
from  the  surface  of  an  ulcer;  or  from  hemorrhoids.  It  is  a  note- 
worthy fact  that  in  all  these  cases  the  discharge  occurs  in  situations 
where  its  external  escape  can  readily  take  place.  This  strange 
deviation  of  the  menstrual  discharge  may  be  taken  as  a  sign  of 
general  ill-health,  and  it  is  usually  met  with  in  delicate  young  women 
of  highly  mobile  nervous  constitution.  It  may,  however,  begin  at 
puberty,  and  it  has  even  been  observed  during  the  whole  sexual  life. 
The  recurrence  is  regular,  and  always  in  connection  with  the  men- 
strual nisus,  although  the  amount  of  blood  lost  is  much  less  than  in 
ordinary  menstruation. 

Cessation  of  Menstruation. — After  a  certain  time  changes  occur 
showing  that  the  woman  is  no  longer  fitted  for  reproduction ;  men- 
struation ceases,  Graafian  follicles  are  no  longer  matured,  and  the 
ovary  becomes  shrivelled  and  wrinkled  on  its  surface.  Analogous 
alterations  take  place  in  the  uterus  and  its  appendages.  The  Fallo- 
pian tubes  atrophy,  and  are  not  unfrequently  obliterated.  The  uterus 
decreases  in  size.  The  cervix  undergoes  a  remarkable  change  which 
is  readily  detected  on  vaginal  examination.  The  projection  of  the 
cervix  into  the  vaginal  canal  disappears,  and  the  orifice  of  the  os 
uteri  in  old  women  is  found  to  be  flush  with  the  roof  of  the  vagina. 
In  a  large  number  of  cases  there  is,  after  the  cessation  of  menstrua- 
tion, an  occlusion  both  of  the  external  and  internal  os;  the  canal  of- 
the  cervix,  however,  between  them  remains  patulous,  and  is  not  un- 
frequently distended  with  a  mucous  secretion. 

Period  of  Cessation. — The  age  at  which  menstruation  ceases  varies 
much  in  different  women.  In  certain  cases  it  may  cease  at  an  unusu- 
ally early  age,  as  between  30  and  40  years,  or  it  may  continue  far 


OVULATION    AND    MEXSTRU ATIOX .  S3 

beyond  the  average  time,  even  up  to  60  years;  and  exceptional, 
though  perhaps  hardly  reliable  instances,  are  recorded  in  which  it 
has  continued  even  to  80  or  90  years.  These  are,  however,  strange 
anomalies,  which,  like  cases  of  unusually  precocious  menstruation, 
cannot  be  considered  as  having  any  bearing  on  the  general  rule. 
Most  cases  of  so-called  protracted  menstruation  will  be  found  to  be 
really  morbid  losses  of  blood  depending  on  malignant  or  other  forms 
of  organic  disease,  the  existence  of  which,  under  such  circumstances, 
should  always  be  suspected. 

In  this  country  menstruation  usually  ceases  between  40  and  50 
years  of  age.  Eaciborski  says  that  the  largest  number  of  cases  of 
cessation  are  met  with  in  the  46th  year.  Is  is  generally  said  that 
women  who  commence  to  menstruate  when  very  young,  cease  to  do 
so  at  a  comparatively  early  age,  so  that  the  average  duration  of  the 
function  is  about  the  same  in  all  women.  Cazeaux  and  Raciborski, 
whose  opinion  is  strengthened  by  the  observations  of  Guy  in  1500 
cases,1  think,  on  the  contrary,  that  the  earlier  menstruation  com- 
mences, the  longer  it  lasts,  early  menstruation  indicating  an  excess 
of  vital  energy  which  continues  during  the  whole  childbearing  life. 
Climate  and  other  accidental  causes,  do  not  seem  to  have  as  much 
effect  on  the  cessation  as  on  the  establishment  of  the  function.  It 
does  not  appear  to  cease  earlier  in  warm  than  in  temperate  climates. 
The  change  of  life  is  generally  indicated  by  irregularities  in  the 
recurrence  of  the  discharge.  It. seldom  ceases  suddenly,  but  it  may 
be  absent  for  one  or  more  periods,  and  then  occur  irregularly;  or  it 
may  become  profuse  or  scanty,  until  eventually  it  entirely  stops. 
The  popular  notions  as  to  the  extreme  danger  of  the  menopause  are 
probably  much  exaggerated;  although  it  is  certain  that  at  that  time 
various  nervous  phenomena  are  apt  to  be  developed.  So  far  from 
having  a  prejudicial  effect  on  the  health,  however,  it  is  not  an  un- 
common observation  to  see  an  hysterical  woman,  who  has  been  for 
years  a  martyr  to  uterine  and  other  complaints,  apparently  take  a 
new  lease  of  life  when  her  uterine  functions  have  ceased  to  be  in 
active  operation,  and  statistical  tables  abundantly  prove  that  the 
general  mortality  of  the  sex  is  not  greater  at  this  than  at  any  other 
time. 

1  Med.  Times  and  Gaz.,  1845. 


PART   II. 

PREGNANCY. 


CHAPTER  I. 


CONCEPTION   AND   GENERATION. 

GENERATION  in  the  human  female,  as  in  all  mammals,  requires 
the  congress  of  the  two  sexes,  in  order  that  the  semen,  the  male  ele- 
ment of  generation,  may  be  brought  into  contact  with  the  ovule,  the 
female  element  of  generation. 

Semen. — The  semen  secreted  by  the  testicle  of  an  adult  male  is  a 
viscid,  opalescent  fluid,  forming  an  emulsion  when  mixed  with 
water,  and  having  a  peculiar  faint  odor,  which  is  attributed  to  the 
secretions  which  are  mixed  with  it,  such  as  those  from  the  prostate 
and  Cowper's  glands.  On  analysis  it  is  found  to  be  an  albuminous 
fluid,  holding  in  solution  various  salts,  principally  phosphates  and 
chlorides,  and  an  animal  substance,  sperrnatine,  analogous  to  fibrine. 
Examined  under  a  magnifying  power  of  from  400  to  500  diameters, 
it  consists  of  a  transparent  and  homogeneous  fluid,  in  which  are  float- 
ing a  certain  number  of  granules  and  epithelial  cells,  derived  from 
the  secretions  mixed  with  it,  and  the  characteristic  sperm  cells  and 

spermatozoa  which  form  its  essen- 
tial constituents  (Fig.  40).  The 
sperm  cells  are  large  spherical 
vesicles,  each  containing  from  two 
to  eight  smaller  cells,  within  which 
the  spermatozoa  are  developed; 
and,  as  these  soon  escape  and  be- 
come free,  the  sperm  cells  are 
only  to  be  detected  in  the  testicles 
themselves,  while  in  semen  that 
has  been  ejaculated  they  are  rarely 
visible.  The  large  parent  cell, 
termed  by  Robin  the  male  ovule, 
forms  within  it  several  subsidiary 
cells  by  the  segmentation  of  its 
granular  contents.  Within  these 
secondary  cells,  or  vesicles  of  evo- 
lution, which  are  believed  by  Kolliker  to  be  developed  from  the 
nuclei  of  the  parent  cell,  the  spermatozoa  are  formed,  and  before 
ejaculation  they  may  be  seen  coiled  spirally  in  their  interior.  The 
external  envelope  then  disappears,  and  a  number  of  spermatozoa,  one 


a,f>.  Sperm  cells  containing  nuclei,  each  nucleus 
having  within  a  spermatozoon,  c.  Nucleus, 
with  nucleoli.  d.  Nucleus,  with  spermato- 
zo m.  e.  A  cell,  with  a  bundle  of  spermatic 
filaments.  /,  g,  h.  Spermatozoa. 


CONCEPTION    AND    GENERATION.  85 

being  formed  in  each  of  the  secondary  cells,  may  be  observed  in  the 
interior  of  the  original  parent  cell.    Eventually  that  also  is  absorbed, 
and  the  contained  spermatozoa  become  liberated,  and  move  about 
freelv  in  the  seminal  fluid.     As  seen  under  the  microscope,  the  sper- 
matozoa, which  exist  in  healthy  semen  in  enormous  numbers,  present 
the  appearance  of  minute  particles,  not  unlike  a  tadpole  in  shape. 
The  head  is  oval  and  flattened,  measuring  about  e^^th  of  an  inch 
in  breadth,  and  attached  to  it  is  a  delicate  filamentous  expansion  or 
tail,  which  tapers  to  a  point  so  fine  that  its  termination  cannot  be 
seen  by  the  highest  powers  of  the  microscope.     The  whole  sperma- 
tozoon measures  from  j-^th  to  g^th  of  an  inch  in  length.     The 
spermatozoa  are  observed  to  be  in  constant  motion,  sometimes  very 
rapid,  sometimes  more  gentle,  which  is  supposed  to  be  the  means 
by  which  they  pass  upwards  through  the   female  genital  organs. 
They  retain  their  vitality  and  power  of  movement  for  a  consider- 
able time  after  emission,  provided  the  semen  is  kept  at  a  tempera- 
ture similar  to  that  of  the  body.     Under  such  circumstances  they 
have  been  observed  in  active  motion  from  forty-eight  to  seventy-two 
hours  after  ejaculation,  and  they  have  also  been  seen  alive  in  the  tes- 
ticle as  long  as  twenty-four  hours  after  death.     In  all  probability 
they  continue  active  much  longer  within  the  generative  organs,  as 
many  physiologists  have  observed  them  in  full  vitality  in  bitches 
and  rabbits,  seven  or  eight  days  after  copulation.    Abundant  leucor- 
rhoeal  discharges  and  acrid  vaginal  secretions  destroy  their  move- 
ments, and  may  thus  cause  sterility  in  the  female.     On  account  of 
their  mobility,  the  spermatozoa  were  long  considered  to  be  indepen- 
dent animalcules,  a  view  which  is  by  no  means  exploded,  and  has  been 
maintained  in  modern  times  by  Pouehet,  Joulin,  and  other  writers, 
while  Coste,  Eobin.  Kolliker,  etc.,  liken  their  motion  to  that  of  cili- 
ated epithelium.    There  can  be  no  doubt  that  the  fertilizing  power  of 
the  semen  is  due  to  the  presence  of  the  spermatozoa,  although  some 
of  the  older  physiologists  assigned  it  to  the  spermatic  fluid.     The 
former  view,  however,  has  been  conclusively  proved  by  the'  experi- 
ments of  PreVost  and  Dumas,  who  found  that  on  carefully  removing 
the  spermatozoa  by  filtration  the  semen  lost  its  fecundating  properties. 
Sites  of  Impregnation. — There  has  been  great  difference  of  opinion 
as  to  the  part  of  the  genital  tract  in  which  the  spermatozoa  and  the 
ovule  come  into  contact,  and  in  which  impregnation,  therefore,  occurs. 
Spermatozoa  have  been  observed  in  all  parts  of  the  female  genital 
organs  in  animals  killed  shortly  after  coitus,  especially  in  the  Fallo- 
pian tubes,  and  even  on  the  surface  of  the  ovary.    The  phenomena  of 
ovarian  gestation,  and  the  fact  that  fecundation  has  been  proved  to 
occur  in  certain  animals  within  the  ovary,  tend  to  support  the  idea 
that  it  may  also  occur  in  the  human  female  before  the  rupture  of  the 
Graafian  follicle.     In  order  to  do  so,  however,  it  is  necessary  for  the 
spermatozoa  to  penetrate  the  proper  structure  of  the  follicle  and  the 
epithelial  covering  of  the  ovary,  and  no  one  has  actually  seen  them 
doing  so.     Most  probably  the  contact  of  the    spermatozoa  and  the 
ovule  occurs  very  shortly  after  the  rupture  of  the  follicle,  and  in  the 
outer  part  of  the  Fallopian  tubes.     Coste  mentions  that,  unless  the 
ovule  is  impregnated,  it  very  rapidly  degenerates  after  being  expelled 


86 


PREGNANCY. 


from  the  ovary,  partly  by  inherent  changes  in  the  ovule  itself,  and 
partly  because  it  then  soon  becomes  invested  by  an  albuminous 
covering  which  is  impermeable  to  the  spermatozoa.  He  believes, 
therefore,  that  impregnation  can  only  occur  either  on  the  surface  of 
the  ovary,  or  just  within  the  ftmbriated  extremity  of  the  tube. 

Mode  in  which  the  ascent  of  the  Semen  is  effected. — The  semen  is 
probably  carried  upwards  chiefly  by  the  inherent  mobility  of  the 
spermatozoa.  It  is  believed  by  some  that  this  is  assisted  by  other 
agencies;  amongst  them  are  mentioned  the  peristaltic  action  of  the 
uterus  and  Fallopian  tubes  ;  a  sort  of  capillary  attraction  effected  when 
the  walls  of  the  uterus  are  in  close  contact,  similar  to  the  movement 
of  fluid  in  minute  tubes ;  and  also  the  vibratile  action  of  the  cilia  of 
the  epithelium  of  the  uterine  mucous  membrane.  The  action  of  the 
latter  is  extremely  doubtful,  for  they  are  also  supposed  to  effect  the 
descent  of  the  ovule,  and  they  can  hardly  act  in  two  opposite  ways. 
The  movement  of  the  cilia  being  from  within  outwards,  it  would  cer- 
tainly oppose,  rather  than  favor,  the  progress  of  the  spermatozoa. 
It  must,  therefore,  be  admitted  that  they  ascend  chiefly  through 
their  own  powers  of  motion.  They  certainly  have  this  power  to  a 
remarkable  extent,  for  there  are  numerous  cases  on  record  in  which 
impregnation  has  occurred  without  penetration,  and  even  when  the 
hymen  was  quite  entire,  and  in  which  the  semen  has  simply  been  de- 
posited on  the  exterior  of  the  vulva ;  in  such  cases,  which  are  far 
from  uncommon,  the  spermatozoa  must  have  found  their  way  through 
the  whole  length  of  the  vagina.  It  is  probable,  however,  that  under 
ordinary  circumstances  the  passage  of  the  spermatic  fluid  into  the 
uterus  is  facilitated  by  changes  which  take  place  in  the  cervix  during 
the  sexual  orgasm,  in  course  of  which  the  os  uteri  is  said  to  dilate 
and  close  again  in  a  rythmical  manner.1 

Mode  of  Impregnation. — The  precise  method  in  which  the  sperma- 
tozoa effect  impregnation  was  long  a  matter  of  doubt.  It  is  now, 
however,  certain  that  they  actually  penetrate  the  ovule,  and  reach  its 

interior.  This  has  been  conclusively 
proved  by  the  observations  of  Barry, 
Meissner,  and  others,  who  have  seen  the 
spermatozoa  within  the  external  mem- 
brane of  the  ovule  in  rabbits  (Fig.  41). 
In  some  of  the  invertebrata  a  canal  or 
opening  exists  in  the  zona  pellucida, 
through  whicn  the  spermatozoa  pass.  No 
such  aperture  has  yet  been  demonstrated 
in  the  ovules  of  mammals,  but  its  existence 
is  far  from  improbable.  According  to  the 
observations  of  Newport,  several  sperma- 
tozoa enter  the  ovule,  and  the  greater  the 

ovum  of  Rabbit  containing  sperma-    number  that  do  so  the  more  certain  fecun- 
tozoa-  dation  becomes.     After  the  spermatozoa 

.  Zona   pellucid..     2.    The  germs       penetrate  the    ZQna  pgHucida  they  disinte- 
consisting  of  two  large  cells,  several  .          .  r  11       i          . 

smaller  ceiis,  and  spermatozoa.          grate  and  mingle  with  the  yelk,  having, 


FIG.  41. 


How  do  the  Spermatozoa  enter  the  Uterus  ?  by  J.  Beck,  M.D. 


CONCEPTION    AND    GENERATION.  8l 

while  doing  so,  imparted  to  the  ovule  a  power  of  vitality,  and  ini- 
tiated its  development  into  a  new  being. 

Progress  of  the  Impregnated  Ovule  toivards  the  Uterus. — The  length 
of  time  which  lapses  before  the  fecundated  ovule  arrives  in  the  cav- 
ity of  the  uterus  has  not  yet  been  ascertained,  and  it  probably  varies 
under  different  circumstances.  It  is  known  that  in  the  bitch  it  may 
remain  eight  or  ten  days  in  the  Fallopian  tube,  in  the  guinea-pig 
three  or  four.  In  the  human  female  the  ovum  has  never  been  dis- 
covered in  the  cavity  of  the  uterus  before  the  tenth  or  twelfth  day 
after  impregnation. 

Changes  immediately  before  and  after  Impregnation. — The  changes 
which  occur  in  the  human  ovule  immediately  before  and  after  im- 
pregnation, and  during  its  progress  through  the  Fallopian  tube,  are 
only  known  to  us  by  analogy,  as,  of  course,  it  is  impossible  to  study 
them  by  actual  observation.  We  are  in  possession,  however,  of  ac- 
curate information  of  what  has  been  made  out  in  the  lower  animals, 
and  it  is  reasonable  to  suppose  that  similar  changes  occur  in  man. 
Immediately  after  the  ovule  has  passed  into  the  Fallopian  tube,  it  is 
found  to  be  surrounded  by  a  layer  of  granular  cells,  a  portion  of  the 
lining  membrane  of  the  Graafian  follicle,  which  was  described  as  the 
discus  proligerus.  As  it  proceeds  along  the  tube  these  surrounding 
cells  disappear,  partly,  it  is  supposed,  by  friction  on  the  walls  of  the 
tube,  and  partly  by  being  absorbed  to  nourish  the  ovule.  Be  this  as 
it  may,  before  long  they  are  no  longer  observed,  and  the  zona  pellu- 
cida  forms  the  outermost  layer  of  the  ovule.  When  the  ovule  has 
advanced  some  distance  along  the  tube,  it  becomes  invested  with  a 
covering  of  albuminous  material,  which  is  deposited  around  it  in  suc- 
cessive layers,  the  thickness  of  which  varies  in  different  animals.  It 
is  very  abundant  in  birds,  in  whom  it  forms  the  familiar  white  of  the 
egg.  In  some  animals  it  has  not  been  detected,  so  that  its  presence 
in  the  human  ovule  is  uncertain.  Where  it  exists  it  doubtless  con- 
tributes to  the  nourishment  of  the  ovule.  Coincident  with  these 
changes  is  the  disappearance  of  the  germinal  vesicle.  At  the  same 
time  the  yelk  contracts  and  becomes  more  solid ;  retiring,  in  one 
spot,  from  close  contact  with  the  zona 
pellucida,  and  thus  forming  a  species  of  FIG.  42. 

cavity  called  by  Newport  the  respira- 
tory chamber,  which  in  some  animals  is 
filled  with  a  transparent  liquid.  After 
this  occurs  the  very  peculiar  phenome- 
non known  as  the  cleavage  of  the  yelk, 
which  results  in  the  formation  of  the 
membrane  from  which  the  fcetus  is  de- 
veloped. It  is  preceded  by  the  forma- 
tion at  one  point  of  the  surface  of  the 
yelk  of  a  minute  transparent  globule  of 

a  bluish  tint,  sometimes  of  three  or  four  rotation  of  the  "  Polar  oiotmie. 
separate  globules  which  subsequently  >•£ •  ™^«-  ^aT  'S™ 
unite  into  one.  This  has  received  the  vesicle.  5.  ThePoiaroiobuie. 


88 


PREGNANCY. 


name  of  the  polar  ylobule  (Fig.  42),  and  seems  to  be  formed  from  the 
hyaline  substance  of  the  yelk,  from  which  it  soon  becomes  entirely 
separated,  and  remains  attached  to  the  inner  surface  of  the  zona 
pellucida.  It  indicates  the  point  at  which  the  segmentation  of  the 
yelk  begins,  and  where  the  cephalic  extremity  of  the  foetus  will  sub- 
sequently be  placed. 

According  to  Kobin  these  changes  occur  in  all  ovules,  whether 
they  are  impregnated  or  not,  but  if  the  ovule  is  not  fecundated,  no 
further  alterations  occur.  Supposing  impregnation  has  taken  place, 
a  bright  clear  vesicle,  called  the  vitelline  nucleus,  very  similar  in 
appearance  to  a  drop  of  oil,  appears  in  the  centre  of  the  yelk.  The 
segmentation  of  the  yelk  (Fig.  43)  commences  at  the  point  where  the 
polar  globule  is  situated ;  it  begins  to  divide  into  two  halves,  and  at 


Segmentation  of  the  Yelk. 

A.  Ovum  with  first  Embryo  cell.    B.  Division  of  embryo  cell  and  cleavage  of  the  yelk  around  it. 
C,  D,  E.  Further  division  of  the  yelk. 

the  same  time  the  vitelline  nucleus  becomes  constricted  in  its  centre, 
and  separates  into  two  portions,  one  of  which  forms  a  centre  for  each 
of  the  halves  into  which  the  yelk  has  divided.  Each  of  these  im- 
mediately divides  into  two,  as  does  its  contained  portion  of  the  vitel- 
line nucleus,  and  so  on  in  rapid  succession  until  the  whole  yelk  is 
divided  into  a  number  of  spheres,  each  of  which  consists  of  a  clump 
of  nucleated  protoplasm. 

By  these  continuous  dichotomous  divisions  the  whole  yelk  is 
formed  into  a  granular  mass  which,  from  its  supposed  resemblance 
to  a  mulberry,  has  been  named  the  muriform  lody.  When  the  sub- 
division of  the  yelk  is  completed,  its  separate  spheres  become  con- 
verted into  cells,  consisting  of  a  fine  membrane  with  granular 
contents.  These  cells  unite  by  their  edges  to  form  a  continuous 
membrane  (Fig.  44),  which,  through  the  expansion  of  the  muriform 
body  by  fluid  which  forms  in  its  interior,  is  distended  until  it  forms 
a  lining  to  the  zona  pellucida.  This  is  the  blastodermic  membrane 
from  which  the  foetus  is  developed.  By  this  time  the  ovum  has 


CONCEPTION    AND    GENERATION. 


89 


reached  the  uterus,  and,  before  proceeding  to  consider  the  further 
changes  which  it  undergoes  it  will  be  Avell  to  study  the  alteration 
•which  the  stimulus  of  impregnation  has  set  on  foot  in  the  mucous 


FIG.  44. 


Formation  of  the  Blastodermic  Membrane  from  the  cells  of  the  Muriforrn  Body.     (After  Joulin.) 
1.  Layer  of  albuminous  material  surrounding.    2.  The  Zona  pellucida. 

membrane  of  the  uterus,  in  order  to  prepare  it  for  the  reception  and 
growth  of  its  contents. 

Changes  in  the  Uterine  Mucous  Membrane  consequent  on  Pregnancy. 
—Even  before  the  ovum  reaches  the  uterus,  the  mucous  membrane 
becomes  thickened  and  vascular,  so  that  its  opposing  surfaces  entirely 
fill  the  uterine  cavity.  These  changes  may  be  said  to  be  the  same 
in  kind,  although  more  marked  and  extensive  in  degree,  as  the  alte- 
rations which  take  place  in  the  mucous  membrane  in  connection 
with  each  menstrual  period.  The  result  is  the  formation  of  a  distinct 
membrane,  which  affords  the  ovum  a  safe  anchorage  and  protection, 
until  its  connections  with  the  uterus  are  more  fully  developed.  After 
delivery,  this  membrane,  which  is  by  that  time  quite  altered  in 
appearance,  is  at  least  partially  thrown  off  with  the  ovum ;  on  which 
account  it  has  received  the  name  of  the  decidua,  or  caduca. 

Divisions  of  the.  Decidua. — The  decidua  consists  of  two  principal 
portions,  which,  in  early  pregnancy,  are  separated  from  each  other 
by  a  considerable  interspace.  One  of  these,  called  the  decidua  vera, 
lines  the  entire  uterine  cavity,  and  is,  no  doubt,  the  original  mucous 
lining  of  the  uterus  greatly  hypertrophied.  The  second,  the  decidua 
reflexa,  is  closely  applied  round  the  ovum ;  and  it  is  probably  formed 
by  the  sprouting  of  the  decidua  vera  around  the  ovum  at  the  point 
on  which  the  latter  rests,  so  that  it  eventually  completely  surrounds 
it.  As  the  ovurn  enlarges,  the  decidua  reflexa  is  necessarily  stretched, 
until  it  comes  everywhere  into  contact  with  the  decidua  vera,  with 
which  it  firmly  unites.  After  the  third  month  of  pregnancy  true 
7 


90  PREGNANCY. 

union  has  occurred,  and  the  two  layers  of  decidua  are  no  longer 
separate.  The  decidua  serotina,  which  is  described  as  a  third  portion, 
is  merely  that  part  of  the  decidua  vera  on  which  the  ovum  rests,  and 
where  the  placenta  is  eventually  developed. 

Views  of  William  and  John  Hunter. — It  is  needless  to  refer  to  the 
various  views  which  have  been  held  by  anatomists  as  to  the  struc- 
ture and  formation  of  the  decidua.  That  taught  by  John  Hunter 
was  long  believed  to  be  correct,  and  down  to  a  recent  date  it  received 
the  adherence  of  most  physiologists.  He  believed  the  decidua  to  be 
an  inflammatory  exudation  which,  on  account  of  the  stimulus  of 
pregnancy,  was  thrown  out  all  over  the  cavity  of  the  uterus,  and 
soon  formed  a  distinct  lining  membrane  to  it.  When  the  ovum 
reached  the  uterine  orifice  of  the  Fallopian  tube  it  found  its  entrance 
barred  by  this  new  membrane,  which  accordingly  it  pushed  before 
it.  This  separated  portion  formed  a  covering  to  the  ovum,  and 
became  the  decidua  reflexa;  while  a  fresh  exudation  took  place  at 
that  portion  of  the  uterine  wall  which  was  thus  laid  bare,  and  this 
became  the  decidua  vera.  William  Hunter  had  much  more  correct 
views  of  the  decidua,  the  accuracy  of  which  were  at  the  time  much 
contested,  but  which  have  recently  received  full  recognition.  He 
describes  the  decidua  in  his  earlier  writings  as  an  hypertrophy  of 
the  uterine  mucous  membrane  itself,  a  view  which  is  now  held  by 
all  physiologists. 

Structure  of  the  Decidua. — When  the  decidua  is  first  formed  it  is  a 
hollow  triangular  sac  lining  the  uterine  cavity  (Fig.  45),  and  having 
three  openings  into  it,  those  of  the  Fallopian  tubes  at  its  upper 
angles,  and  one,  corresponding  to  the  internal  os  uteri,  below.  If, 
as  is  generally  the  case,  it  is  thick  and  pulpy,  these  openings  are 
closed  up  and  can  no  longer  be  detected.  In  early  pregnancy  it  is 
well  developed,  and  continues  to  grow  up  to  the  third  month  of 
utero-gestation.  After  that  time  it  commences  to  atrophy,  its  adhe- 
sion with  the  uterine  walls  lessens,  it  becomes  thin  and  transparent, 
and  is  ready  for  expulsion  when  delivery  is  effected.  When  it  is 
most  developed,  a  careful  examination  of  the  decidua  enables  us  to 
detect  in  it  all  the  elements  of  the  uterine  mucous  membrane  greatly 
hypertrophied.  Its  substance  chiefly  consists  of  large  round  or  oval 
nucleated  cells  and  elongated  fibres,  mixed  with  the  tubular  uterine 
gland  ducts,  which  are  much  elongated  and  filled  with  cylindrical 
epithelium  cells,  and  a  small  quantity  of  milky  fluid.  According  to 
Friedlander  the  decidua  is  divisible  into  two  layers:  the  inner  being 
'formed  by  a  proliferation  of  the  corpuscles  of  the  sub-epithelial  con- 
nective tissue  of  the  mucous  membrane;  the  deeper,  in  contact  with 
the  uterine  walls,  out  of  flattened  or  compressed  gland  ducts.  In  an 
early  abortion  the  extremities  of  these  ducts  may  be  observed  by  a 
lens  on  the  external  or  uterine  surface  of  the  decidua,  occupying  the 
summit  of  minute  projections,  separated  from  each  other  by  depres- 
sions. If  these  projections  be  bisected  they  will  be  found  to  contain 
little  cavities,  filled  with  lactescent  fluid,  which  were  first  described 
by  Montgomery  of  Dublin,  and  are  known  as  Montgomery's  cups. 
They  are  in  fact  the  dilated  canals  of  the  uterine  tubular  glands. 


CONCEPTION    AND    GENERATION. 


91 


On  the  internal  surface  of  such  an  early  decidua  a  number  of  shallow 
depressions  may  be  made  out,  which  are  the  open  mouths  of  these 
ducts. 

FIG.  45. 


Aborted  Ovum  of  about  forty  days,  showing  the  Triangular  Shape  of  the  Decidua  (which  is  laid 
open),  and  the  Aperture  of  the  Fallopian  Tube.     (After  Coste.) 

Formation  of  the  Decidua  Reflexa. — When  the  ovum  reaches  the 
uterine  cavity  it  soon  becomes  imbedded  in  the  folds  of  the  hyper- 
trophied  mucous  membrane,  which  almost  entirely  fills  the  uterine 


FIG.  46. 


FIG.  47. 


FIG.  48. 


Formation  of  Det-idua. 
(The  decidua  is  colored 
black,  the  ovum  is  repre- 
sented as  engaged  between 
two  projecting  folds  of 
membrane.) 


Projecting  Folds  of  Membrane 
growing  up  around  the  ovum. 


(After  Dalton.) 


Showing  Ovum  completely 
surrounded  by  the  Decidua 
Reflexa. 


cavity.     As  a  rule  it  is  attached  to  some  point  near  the  opening  of 
a  Fallopian  tube,  the  swollen  folds  of  mucous  membrane  preventing 


92  PREGNANCY. 

its  descent  to  the  lower  part  of  the  uterus ;  in  exceptional  circum- 
stances, however,  as  in  women  who  have  borne  many  children,  and 
have  a  more  than  usually  dilated  uterine  cavity,  it  may  fix  itself  at 
a  point  much  nearer  the  internal  os  uteri.  According  to  the  now 
generally  accepted  opinion  of  Coste,  the  mucous  membrane  at  the 
base  of  the  ovum  soon  begins  to  sprout  around  it  and  gradually  ex- 
tends until  it  eventually  completely  covers  the  ovum  (Figs.  46-48), 
and  forms  the  decidua  reflexa.  Coste  describes,  under  the  name  of 
the  umbilicus,  a  small  depression  at  the  most  prominent  part  of  the 
ovum,  which  he  considers  to  be  the  indication  of  the  point  where  the 
closure  of  the  decidua  reflexa  is  effected.  There  are  some  objections 
to  this  theory,  for  no  one  has  seen  the  decidua  reflexa  incomplete 
and  in  the  process  of  formation,  and,  on  examining  its  external  surface, 
that  is,  the  one  furthest  from  the  ovum,  its  microscopical  appearance 
is  identical  with  that  of  the  inner  surface  of  the  decidua  vera.  To 
meet  these  difficulties,  Weber  and  Groodsir,  whose  views  have  been 
adopted  by  Priestley,  contended  that  the  decidua  reflexa  is  "the 
primary  lamina  of  the  mucous  membrane,  which,  when  the  ovum 
enters  the  uterus,  separates  in  two- thirds  of  its  extent  from  the  layers 
beneath  it,  to  adhere  to  the  ovum ;  the  remaining  third  remains 
attached,  and  forms  a  centre  of  nutrition."  According  to  this  view 
the  decidua  vera  would  be  a  subsequent  growth  over  the  separated 
portion,  and  the  decidua  serotina  the  portion  of  the  primary  lamina 
which  remained  attached.  In  this  way  the  fact  of  the  opposed  sur- 
faces of  the  decidua  vera  and  reflexa  being  identical  in  structure 

FIG.  49. 


An  Ovum  removed  from  Uterus,  and  part  of  the  Decidua  Vera  cut  away.     (After  Coste.) 
".  Decidua  vera,  showing  the  follicles  opening  on  its  inner  surface,     b.  Inner  extremity  of  Fallo- 
pian tube,     c.  Flap  of  decidua  reflexa.    d.  Ovum. 

would  be  accounted  for.  The  difficulty  which  this  theory  is  intended 
to  meet,  does  not  seem  so  great  as  is  supposed,  for  if,  as  is  likely,  it 
is  only  the  epithelial  or  internal  surface  of  the  mucous  membrane 


CONCEPTION    AND    GENERATION.  93 

which  sprouts  over  the  ovum,  and  not  its  deeper  layers,  the  facts  of 
the  case  would  be  sufficiently  met  by  Coste's  view. 

Up  to  the  third  month  of  pregnancy  the.  decidua  reflexa  and  vera  are 
not  in  close  contact,  and  there  may  even  be  a  considerable  interspace 
between  them,  which  sometimes  contains  a  small  quantity  of  mucous 
fluid,  called  the  hydroperione.  This  fact  may  account  for  the  curious 
circumstance,  of  which  many  instances  are  on  record,  that  a  uterine 
sound  may  be  passed  into  a  gravid  uterus  in  the  early  months  of 
pregnancy  without  necessarily  producing  abortion,  and  also  for  the 
occasional  occurrence  of  menstruation  after  conception  (Figs.  49  and 
75).  Eventually,  by  the  growth  of  the  ovum,  the  decidua  reflexa 
comes  closely  into  contact  with  the  vera,  and  the  two  become  inti- 
mately blended  and  inseparable. 

Decidua  at  the  end  of  Pregnancy  and  after  Delivery. — As  pregnancy 
advances  the  decidua  alters  in  appearance  and  becomes  fibrous  and 
thin.  In  the  later  months  of  utero-gestation  fatty  degeneration  of 
its  structure  commences,  its  vessels  and  glands  are  obliterated,  and 
its  adhesion  to  the  uterine  walls  is  lessened,  so  as  to  prepare  it  for 
separation.  As  we  shall  subsequently  see,  this  fatty  degeneration 
was  assumed  by  Simpson  to  be  the  determining  cause  of  labor  at 
term. 

Views  of  Roliin.- — It  was  long  believed  that  the  entire  decidua  was 
thrown  off  after  labor,  leaving  the  muscular  coat  of  the  uterus  bare 
and  denuded,  and  that  a  new  mucous  membrane  was  formed  during 
convalescence.  According  to  Eobin,1  whose  views  are  corroborated 
by  Priestley,  no  such  denudation  of  the  muscular  tissue  of  the  uterus 
ever  occurs,  but  a  portion  of  the  decidua  always  remains  attached 
after  delivery.  After  the  fourth  month  of  pregnancy  they  believe 
that  a  new  mucous  membrane  is  formed  under  the  decidua,  which 
remains  in  a  somewhat  imperfect  condition  till  after  delivery,  when 
it  rapidly  develops  and  assumes  the  proper  functions  of  the  mucous 
lining  of  the  uterus.  Robin  also  believes  that  that  portion  of  the 
decidua  which  covers  the  placental  site,  the  so-called  decidua  serotina, 
is  not  thrown  off  with  the  membranes,  like  the  decidua  vera  and 
reflexa,  but  remains  attached  to  the  uterine  walls,  a  thin  layer  of  it 
only  being  expelled  with  the  placenta,  on  which  it  may  be  observed. 
Duncan2  entirely  dissents  from  these  views,  and  does  not  admit  the 
formation  of  a  new  mucous  membrane  during  the  later  months  of 
utero-gestation.  He  believes  that  the  greater  portion  of  the  decidua 
is  thrown  off,  but  that  part  remains,  and  from  this  the  fresh  mucous: 
membrane  is  developed.  This  view  is  similar  to  that  of  Spiegelberg, 
who  holds  that  the  portion  of  the  decidua  that  is  expelled  is  the  more 
superficial  of  the  two  layers  described  by  Friedlander,  composed1 
chiefly  of  the  epithelial  elements,  while  the  deeper  or  glandular 
layer  remains  attached  to  the  walls  of  the  uterus.  From  the  epithe- 
lium of  the  glands  a  new  epithelial  layer  is  rapidly  developed  after 
delivery.  This  theory  bears  on  the  well-known  analogy  of  the  uterus 

1  M6moires  de  1'Acad.  Imp.  de  M£d.  1861. 

2  Researches  in  Obstetrics,  p.  186  et  seq. 


1)4 


PREGNANCY 


after  delivery  to  the  stump  of  an  amputated  limb;  an  old  simile, 
principally  based  on  the  erroneous  theory  that  the  whole  muscular 
tissue  of  the  uterus  was  laid  bare.  This,  as  we  have  seen,  is  not  the 
case,  but  the  simile  so  far  holds  good  in  that  the  mucous  lining  is 
deprived  of  its  epithelial  covering ;  and  this  fact,  together  with  the 
existence  of  numerous  open  veins  on  the  interior  of  the  uterus,  readily 
explains  the  extreme  susceptibility  to  septic  absorption  which  forms 
so  peculiar  a  characteristic  of  the  puerperal  state. 

Changes  in  the  Ovum. — Before  we  commenced  the  study  of  the  de- 
cidua  we  had  traced  the  impregnated  ovum  into  the  uterine  cavity, 
and  described  the  formation  of  the  blastodermic  membrane  by  the 
junction  of  the  cells  of  the  muriforrn  body.  We  must  now  proceed 
to  consider  the  further  changes  which  result  in  the  development  of 
the  foetus,  and  of  the  membranes  that  surround  it.  It  would  be 
quite  out  of  place  in  a  work  of  this  kind  to  enter  into  the  subject  of 
embryology  at  any  length,  and  we  must  therefore  be  content  with 
such  details  as  are  of  importance  from  a  practical  point  of  view. 

Division  of  the  Blastoderms  Membrane,  into  Layers. — The  blasto- 
dermic membrane,  which  forms  a  complete  spherical  lining  to  the 
ovum,  between  the  yelk  and  the  zona  pellucida,  soon  divides  into 
two  layers,  the  most  external,  called  the  epiblast,  and  an  internal,  the 
hypoblast,  and  between  them  is  subsequently  developed  a  third  known 
as  the  mesoblast.  From  these  three  layers  are  formed  the  entire- 
foetus;  the  epiblast  giving  origin  to  the  bones,  muscles,  and  integu- 
ments, the  nervous  system,  the  serous  membranes,  and  the  amnion  ; 
the  hypoblast  forming  the  mucous  membranes  and  the  alimentary 
canal ;  and  the  mesoblast  the  circulating  system. 

TJte  Area  Germinativa. — Almost  immediately  after  the  separation  of 
the  blastodermic  membrane  into  layers,  one  part  of  ifbecomes  thick- 
ened by  the  aggregation  of  cells,  and  is  called  the  area  yerminativa . 

FIG.  50. 


Diagram  of  area  gorminativa,  showing  the  primitive  trace  and  aroa  i  elluci<la. 

This  is  at  first  round  and  then  oval  in  shape,  and  in  its  centre  the 
iirst  trace  of  the  foetus  may  be  detected  in  the  form  of  a  narrow 
straight  line,  the  primitive  trace.  Surrounding  it  are  some  cells  more 
translucent  than  those  of  the  rest  of  the  area  germinativa,  and  hence 


CONCEPTION    AND    GENERATION. 


9f> 


called  the  area  pellucida  (Fig;.  50).  On  each  side  of  the  primitive 
trace  two  elevated  ridges  soon  arise,  the  laminae  dorsales,  which  grad- 
ually unite  posteriorly, to  form  a  cavity  within  which  the  cerebro- 
spinal  column  is  subsequently  developed.  Anteriorly  they  join  to 
form  the  thoracic  arid  abdominal  cavities,  inclosing  portions  of  the 
epiblast,  from  which  the  serous  membranes  of  the  body  are  devel- 
oped. The  minute  embryo  thus  formed  soon  curves  on  itself,  with 
its  convexity  outwards,  and  a  distinct  thickening  is  observed  at  one 
end,  which  is  subsequently  developed  into  the  cephalic  extremity  of 
the  foetus,  while,  at  its  other  end,  a  thickening  less  marked  in  degree 
forms  the  caudal  extremity. 

Formation  of  the  Amnion. — At  each  of  these  points,  very  soon  after 
the  formation  of  the  embryo,  two  hollow  processes  may  be  observed 
which  gradually  arch  over  the  dorsal 
surface  of  the  foetus,  until  they  meet 
each  other  and  form  a  complete  en- 
velope to  it.  At  the  ventral  surface 
these  processes  are  separated  by  the 
whole  length  of  the  embryo,  but  they 
here  also  gradually  approach  each 
other,  and  eventually  surround  what 
is  subsequently  the  umbilical  cord, 
and  blend  with  the  integument  of  the 
fcetus  at  the  point  of  its  insertion.  In 
this  way  is  formed  the  amnion  (Fig. 
51),  consisting  of  two  layers ;  the  in- 
ternal, derived  from  the  epiblast,  is 
formed  of  tessellated  epithelial  cells, 
the  external  arising  from  the  meso- 
blast,  is  formed  of  cells  like  those  of 
young  connective  tissue.  Before  the 
folds  of  the  amnion  unite,  the  free  edge 
of  each  is  bent  outwards  and  spreads 
around  the  ovum,  immediately  within  the  zona  pellucida,  forming  a 
lining  to  it,  termed  by  Turner  the  sub-zonal  membrane,  which  is  con- 
nected with  the  development  of  the  chorion.  The  amnion  is  the  most 
internal  of  the  membranes  surrounding  the  fcetus,  and  will  presently 
be  studied  more  in  detail.  It  soon  becomes  distended  with  fluid,  the 
liquor  amnii,  and  as  this  increases  in  amount  it  separates  the  amnion 
more  and  more  from  the  uterus. 

Changes  in  the  Mucous  Layer. — During  this  time  the  innermost 
layer  of  the  blastodermic  membrane  or  hypoblast  is  also  developing- 
two  projections  at  either  extremity  of  the  fcetus,  and  these  gradually 
approach  each  other  anteriorly.  As  the  hypoblast  is  in  contact  with 
the  yelk,  when  these  meet  they  have  the  effect  of  dividing  the  yelk 
into  two  portions.  One,  and  the  smaller  of  the  two,  forms  eventu- 
ally the  intestinal  canal  of  the  fcetus ;  the  other,  and  much  the  larger, 
contains  the  greater  portion  of  the  yelk,  and  forms  the  ephemeral 
structure  known  as  the  umbilical  vesicle,  from  which  the  fcetus  derives 
most  of  its  nourishment  during  the  early  stage  of  its  existence.  Its 


Development  of  the  Amniou. 
1.  Vitelline  membrane.  2.  External  layer 
of  blastodermic  membrane.  3.  Internal 
layers  forming  the  umbilical  vesicle.  4. 
Umbilical  vessels.  5.  Projections  form- 
ing minium.  6.  Allantois. 


96 


PREGNANCY. 


communication  with  the  abdominal  cavity  of  the  foetus  is  through 
the  constricted  portion  at  the  point  of  division  called  the  vitelline 
duct  (Fig.  52).  An  artery  and  vein,  the  omphalo-mesenteric,  ramify 
on  the  vesicle  and  its  duct. 

FIG.  52. 


FIG. 53. 


1.  Exo-chorion.    2.  External  layer  of  blastodermic  membrane.    3.  Umbilical  vesicle.    4.  Its  vessels. 
5.  Aumion.    6.  Embryon.    7.  Allautois  increasing  in  size. 

As  the  amnion  increases  in  size,  it  pushes  back  the  umbilical 
vesicle  towards  the  external  membrane  of  the  ovum,  between  which 
and  the  amnion  it  lies  (Fig.  53) ;  and  when  the  allantois  is  developed, 
it  ceases  to  be  of  any  use,  and  rapidly  shrinks  and  dwindles  away. 
In  most  mammals  no  trace  of  it  can  be  found 
after  the  fourth  month  of  utero-gestation ;  in 
some,  including  the  human  female,  it  is  said  to 
exist  as  a  minute  vesicle  at  the  placental  end  of 
the  umbilical  cord  at  the  full  period  of  preg- 
nancy. The  umbilical  vesicle  is  filled  with  a 
yellowish  fluid,  containing  many  oil  and  fat 
globules,  similar  to  the  yelk  of  an  egg. 

The  Allantois. — Somewhere  about  the  twen- 
tieth day  after  conception  a  small  vesicle  is 
formed  towards  the  caudal  extremity  of  the 
foetus,  which  is  called  the  allantois.  It  is  well 
developed  and  persistent  in  many  of  the  lower 
animals,  but  in  man  it  is  merely  a  temporary 
structure,  and  disappears  after  it  has  fulfilled  its 
functions.  Its  study,  therefore,  in  the  human 
race  has  been  a  matter  of  difficulty,  and  it  was 
long  before  we  were  possessed  of  any  very  re- 
liable information  regarding  it.  There  has  been 
some  difference  of  opinion  as  to  its  precise  mode  of  origin.  The 
most  generally  received  opinion  is  that  it  begins  as  a  diverticulum 
from  the  lower  part  of  the  intestinal  canal.  This,  at  first  spherical, 
rapidly  develops  and  becomes  pyriform  in  shape,  while,  by  a  process 
of  constriction,  similar  to  that  which  occurs  in  the  vitellus  to  form 


An  Embryo  of  about  twen- 
ty-five   days    laid   open. 
(After  Coste.) 
a.  Chorion.      6.  Amnion. 
<?.  Cavity  of  chorion.     d. 
Umbilical  vesicle,    e.  Pedi- 
cle  of   allantois.    /.    Em- 
bryo. 


CONCEPTION    AND    GENERATION. 


97 


the  umbilical  vesicle,  it  becomes  divided  into  two  parts,  communi- 
cating with  each  other,  the  smaller  of  them  being  eventually  de- 
veloped into  the  urinary  bladder.  The  larger  portion,  leaving  the 
abdominal  cavity  along  with  the  vitelline  duct,  rapidly  grows  until 
it  comes  into  contact  with  the  most  external  ovular  membrane,  the 
chorion,  over  the  entire  inner  surface  of  which  it  spreads.  In  this 
part  vessels  soon  develop :  namely,  the  two  umbilical  arteries,  de- 
rived from  the  abdominal  aorta,  and  two  umbilical  veins,  one  of 
which  subsequently  disappears ;  these,  along  with  the  vitelline  duct 
and  the  pedicle  of  the  allantois,  form  the  umbilical  cord.  The  main 
and  very  important  function  of  the  allantois,  therefore,  is  to  carry 
the  foetal  vessels  up  to  the  inner  surface  of  the  sub-zonal  membrane. 


].   Exo-chorion.    2.  External  layer  of  the  blastodermic  membrane.     3.  Allantois 
4.  Umbilical  vesicle.     5.  Amnion.     6.  Embryon.     7.  Pedicle  of  Allantcis. 

Besides  this  purpose,  the  allantois,  at  a  very  early  period,  may  receive 
the  excretions  of  the  foetus,  and  serve  as  an  excrementitious  organ. 
According  to  Cazeaux,  scarcely  a  trace  of  the  allantois  can  be  seen 
a  few  days  after  its  formation.  Its  lower  part  or  pedicle,  however, 
long  remains  distinct,  and  forms  part  of  the  umbilical  cord ;  and 
traces  of  it  may  be  found  even  in  adult  life  in  the  form  of  the  urachus, 
which  is  really  the  dwindled  pedicle,  and  forms  one  of  the  ligaments 
of  the  bladder. 

The  Corps  Reticule  or  Vitriform  Body. — Between  the  chorion  and 
amnion  is  often  found  a  gelatinous  fluid,  with  minute  filamentous 
processes  traversing  it,  called  by  Velpeau  the  corps  reticule,  which 
is  not  met  with  until  the  allantois  comes  into  contact  with  the  cho- 
rion, and  which  seems  to  be  formed  out  of  the  tissue  of  that  vesicle. 
It  is  analogous  to  the  so-called  Wharton's  jelly  found  in  the  umbilical 
cord.  When  first  formed  it  is  highly  vascular,  but  the  vessels 
entirely  disappear  after  the  placenta  is  formed,  and  the  remainder  of 
the  chorionic  villi  atrophy.  Sometimes  it  exists  in  considerable 
quantities,  and  should  the  chorion  rupture  at  the  end  of  pregnancy, 


08  ,  PREGNANCY. 

it  may  escape  and  give  rise  to  an  erroneous  impression  that  the 
liquor  amnii  has  been  discharged. 

Recapitulation. — Before  proceeding  to  consider  the  fcetal  envelopes 
more  at  length,  it  may  be  useful  to  recapitulate  the  structures  already 
alluded  to  as  forming  the  ovum.  In  this  we  find : — 

1.  The  embryo  itself. 

2.  A  fluid,  the  liquor  amnii,  in  which  it  floats. 

3.  The  amnion,  a  purely  fcetal  membrane  surrounding  the  embryo, 

••IT" 

and  containing  the  liquor  amnii. 

4.  The  umbilical  vesicle,  containing  the  greater  portion  of  the  yelk, 
serving  as  a  source  of  nutrition  to  the  early  embryo  through  the 
vitelline  duct,  and  in  which  ramify  the  omphalo-rnesenteric  vessels. 

5.  The  allantois,  a  vesicle  proceeding  from  the  caudal  extremity 
of  the  embryo,  spreading  itself  over  the  interior  of  the  ovum,  and 
serving  as  a  channel  of  vascular  communication  between  the  chorion 
and  the  foetus,  through  the  umbilical  vessels. 

6.  An  interspace  between  the  outer  layer  of  the  ovum  and  the 
amnion,  in  which  is  contained  the  umbilical  vesicle  and  allantois,  and 
the  corps  reticule  of  Velpeau. 

7.  The  outer  layer  of  the  ovum,  along  with  the  sub-zonal  mem- 
brane, forming  the  chorion  and  placenta. 

Amnion. — The  amnion  is  the  most  internal  of  the  two  membranes 
surrounding  the  foetus ;  its  origin  at  an  early  period  of  fcetal  life  has 
already  been  described.  It  is  a  perfectly  smooth,  transparent,  but 
tough  membrane,  continuous  with  the  integument  of  the  foetus  at  tilt- 
insertion  of  the  umbilical  cord,  round  which  it  forms  a  sheath.  Soon 
•after  it  is  formed  it  becomes  distended  with  a  fluid,  the  liquor  amnii, 
in  which  the  foetus  is  suspended  and  floats.  This  fluid  increases 
gradually  in  quantity,  distending  the  amnion  as  it  does  so,  until  this 
is  brought  into  contact  with  the  inner  surface  of  the  chorion,  from 
which  it  was  at  first  separated  by  a  considerable  interspace. 

Structure. — The  internal  surface  of  the  amnion  is  smooth  and 
glistening,  and  on  microscopic  examination  it  is  found  to  consist  of 
a  layer  of  flattened  cells,  each  containing  a  large  nucleus.  These 
rest  on  a  stratum  of  fibrous  tissue  which  gives  to  the  membrane  its 
toughness,  and  by  which  it  is  attached  to  the  inner  surface  of  the 
chorion.  It  is  entirely  destitute  of  vessels,  nerves,  and  lymphatics. 
The  quantity  of  the  liquor  amnii  varies  much  at  different  periods  of 
pregnancy.  In  the  early  months  it  is  relatively  greater  in  amount 
than  the  foetus,  which  it  outweighs.  As  pregnancy  advances,  the 
weight  of  the  foetus  becomes  four  or  five  times  greater  than  that  of 
the  liquor  arnnii,  although  the  actual  quantity  of  fluid  increases  dur- 
ing the  whole  period  of  gestation.  The  amount  of  fluid  varies  much 
in  different  pregnancies.  Sometimes  there  is  comparatively  little ; 
while  at  others  the  quantity  is  immense,  reaching  several  pounds 
in  weight,  greatly  distending  the  uterus,  and  thus,  it  may  be, 
producing  difficulty  in  labor. 

Its  Quality. — At  first  the  liquid  is  clear  and  limpid.  As  pregnancy 
advances  it  becomes  more  turbid  and  dense,  from  the  admixture  of 
epithelial  debris  derived  from  the  cutaneous  surface  of  the  foetus. 


CONCEPTION    AND    GENERATION.  09 

In  some  cases,  without  actual  disease,  it  may  be  dark  green  in  color, 
and  thick  and  tenacious  in  consistency.  It  has  a  peculiar  heavy 
odor,  and  it  consists  chemically  of  water  containing  albumen,  with 
various  salts,  principally  phosphates  and  chlorides. 

Its  Source. — -The  source  of  the  liquor  amnii  has  been  much  disputed. 
Some  maintain  that  it  is  derived  chiefly  from  the  foetus,  a  view  suffi- 
ciently disproved  by  the  fact  that  the  liquor  amnii  continues  to  in- 
crease in  amount  after  the  death  of  the  foetus.  Burdach  believed 
that  it  is  secreted  by  the  internal  surface  of  the  uterus,  and  arrives 
in  the  cavity  of  the  amnion  by  transudation  through  the  membrane. 
Priestley — and  this  seems  the  most  probable  hypothesis — thinks  that 
it  is  secreted  by  the  epithelial  cells  lining  the  membrane,  which 
become  distended  with  fluid,  burst,  and  pour  their  contents  into  the 
amniotic  cavity. 

Functions  and  Uses. — The  most  obvious  use  of  the  liquor  amnii  is 
to  afford  a  fluid  medium  in  which  the  foetus  floats,  and  so  is  protected 
from  the  shocks  and  jars  to  which  it  would  otherwise  be  subjected, 
and  from  undue  pressure  from  the  uterine  walls.  By  distending  the 
uterus  it  saves  the  uterus  from  injury,  which  the  movements  of  the 
foetus  might  otherwise  inflict,  and  the  foetus  is  thus  also  enabled  to 
change  its  position  freely.  The  facility  with  which  version  by  ex- 
ternal manipulation  can  be  effected  depends  entirely  on  the  rnobility 
of  the  foetus  in  the  fluid  which  surrounds  it.  Some  have  also  supposed 
that  it  prevents  the  foetus,  in  the  early  months  of  pregnancy,  from 
forming  adhesions  to  the  arnnion.  In  labor  it  is  of  great  service,  by 
lubricating  the  passages,  but  chiefly  by  forming,  with  the  membranes 
a  fluid  wedge,  which  dilates  the  circle  of  the  os  uteri. 

Chorion. — The  chorion  is  the  more  external  of  the  truly  foetal  mem- 
branes, although  external  to  it  is  the  decidua,  having  a  strictly  ma- 
ternal origin.  It  is  a  perfectly  closed  sac,  its  external  surface,  in 
contact  with  the  decidua,  being  rough  and  shaggy  from  the  develop- 
ment of  villi  (Fig.  50),  its  internal  smooth  and  shining.  As  the 
ovum  passes  along  the  Fallopian  tube  it  receives,  as  we  have  seen, 
an  albuminous  coating,  and  this,  with  the  zona  pellucida,  is  devel- 
oped into  a  temporary  structure,  the  primitive  chorion.  On  its  exter- 
nal surface  villous  prominences  soon  appear,  which  have  no  ascer- 
tained structure,  and  which  seem  to  supply  the  early  ovum  with 
nutriment  by  endosmotic  absorption  from  the  mucous  membrane  of 
the  uterus.  This  primitive  chorion,  however,  has  not  been  observed 
in  the  human  subject,  although  it  may  be  readily  seen  in  the  ova  of 
some  of  the  lower  animals,  such  as  the  dog  and  the  rabbit.  Some 
twelve  days  after  conception,  when  the  blastodermic  membrane  is 
formed,  the  true  chorion  appears.  This  is,  in  fact  formed  by  the 
epiblast  layer  of  the  blastodermic  membrane,  which  everywhere  lines 
the  zona  pellucida  or  primitive  chorion,  and,  by  pressure,  causes  its 
absorption  and  disappearance.  On  the  surface  of  the  true  chorion 
thus  formed,  which  is  now  the  external  envelope  of  the  ovum,  villi 
soon  appear. 

Formation  of  the  Villi. — These  villi  are  hollow  projections  like  the 
fingers  of  a  glove,  which  are  raised  up  from  the  surface  of  the  cho- 


PREGNANCY. 

rion  (the  hollows  looking  into  the  chorionic  cavity),  and  they  cover 
the  whole  external  surface  of  the  ovum,  giving  it  the  peculiar  shaggy 
appearance  observed  in  early  abortions.  They  push  themselves  into 
the  substance  of  the  decidua,  with  which  they  soon  become  so  firmly 
united  that  they  cannot  be  separated  without  laceration.  At  first 
they  are  absolutely  non-vascular,  but  soon  the  allantois,  previously 
described,  reaches  the  inner  surface  of  the  chorion,  and  spreads  itself 
over  the  whole  of  it.  Each  villus  nowr  receives  a  separate  artery  and 
vein,  which  gives  off  a  branch  to  each  of  the  sub-divisions  into  which 
the  villus  divides.  These  vessels  are  encased  in  a  fine  sheath  of  the 
allantois,  which  enters  the  villus  along  with  them  and  forms  a  lining 
to  it,  described  by  some  as  the  endochorion ;  the  external  epithelial 
membrane  of  the  villus,  derived  from  the  epiblast  layer  of  the  blasto- 
dermic  membrane,  being  called  the  exo-chorion.  The  artery  and 
vein  lie  side  by  side  in  the  centre  of  the  villus  and  anastomose  at  its 
extremity  ;  each  villus  thus  having  a  separate  circulation. 

Growth  and  Atrophy  of  the  Villi. — As  soon  as  the  union  of  the 
allantois  with  the  chorion  has  been  effected,  the  villi  grow  very 
rapidly,  give  off  branches,  which,  in  their  turn,  give  off  secondary 
branches,  and  so  form  root-like  processes  of  great  complexity.  In 
the  early  months  of  gestation  they  exist  equally  over  the  whole  sur- 
face of  the  ovum.  As  pregnancy  advances,  however,  those  which  are 
in  contact  with  the  decidua  reflexa  shrivel  up  and,  by  the  end  of  the 
second  month,  disappear,  being  no  longer  required  for  the  nutrition 
of  the  ovum.  The  chorion  and  decidua  thus  come  into  close  contact, 
being  united  together  by  fibrous  shreds,  which,  on  microscopic  ex- 
amination, are  found  to  consist  of  the  atrophied  villi.  A  certain 
number  of  the  villi,  viz.,  those  which  are  in  contact  with  the  decidua 
serotina,  instead  of  dwindling  away  increase  greatly  in  size,  and 
eventually  develop  into  the  organ  by  which  the  foetus  is  nourished 
— the  placenta. 

Form  of  the  Placenta. — This  important  organ  serves  the  purpose 
of  supplying  nutriment  to,  and  aerating  the  blood  of,  the  foetus,  and 
on  its  integrity  the  existence  of  the  foetus  depends.  It  is  met  with 
in  all  mammals,  but  is  very  different  in  form  and  arrangement  in 
different  classes.  Thus,  in  the  sow,  mare,  and  in  the  cetacea,  it  is 
diffused  over  the  whole  interior  of  the  uterus ;  in  the  ruminants,  it 
is  divided  into  a  number  of  separate  small  masses,  scattered  here  and 
there  over  the  uterine  walls ;  while  in  the  carnivora  and  elephant,  it 
forms  a  zone  or  belt  round  the  uterine  cavity.  In  the  human  race, 
as  well  as  in  rodentia,  insectivora,  etc.,  the  placenta  is  in  the  form  of 
a  circular  mass,  attached  generally  to  some  part  of  the  uterus  near 
the  orifices  of  the  Fallopian  tubes ;  but  it  may  be  situated  anywhere 
in  the  uterine  cavity,  even  over  the  internal  os  uteri.  As  it  is  ex- 
pelled after  delivery  with  the  foetal  membranes  attached  to  it,  and  as 
the  aperture  in  these  corresponds  to  the  os  uteri,  we  can  generally 
determine  pretty  accurately  the  situation  in  which  the  placenta  was 
placed,  by  examining  them  after  expulsion.  The  maternal  surface 
of  the  placenta  is  somewhat  convex,  the  foetal  concave.  Its  size 
varies  greatly  in  different  cases,  and  it  is  usually  largest  when  the 


CONCEPTION    AND    GENERATION.  101 

child  is  big,  but  not  necessarily  so.  Its  average  diameter  is  from 
six  to  eight  inches,  its  weight  from  18  to  24  oz.,  but,  in  exceptional 
cases,  it  has  been  found  to  weigh  several  pounds.  Abnormalities  of 
form  are  not  very  rare.  Thus,  the  placenta  has  been  found  to  be 
divided  into  distinct  parts,  a  form  said  by  Professor  Turner  to  be 
normal  in  certain  genera  of  monkeys ;  or  smaller  supplementary 
placentas  (placentae  succentarise),  may  exist  round  a  central  mass. 
These  variations  of  shape  are  only  of  importance  in  consequence  of 
a  risk  of  part  of  the  detached  placenta  being  left  in  utero  after 
delivery,  and  giving  rise  to  septicoamia  or  secondary  hemorrhage. 

Attachment  of  the  Membranes. — The  foetal  membranes  cover  the 
whole  foetal  surface  of  the  placenta,  being  reflected  from  its  edges  so 
as  to  line  the  uterine  cavity,  and  being  expelled  with  it  after  delivery. 
They  also  leave  it  at  the  insertion  of  the  cord,  to  which  they  form  a 
sheath.  The  cord  is  generally  attached  near  the  centre  of  the  pla- 
centa, and  from  its  insertion  the  umbilical  vessels  may  be  seen 
dividing  and  radiating  over  the  whole  foetal  surface. 

Its  Maternal  Surface. — The  maternal  surface  is  rough  and  divided 
by  numerous  sulci,  which  are  best  seen  if  the  placenta  is  rendered 
convex,  so  as.  to  resemble  its  condition  when  attached  to  the  uterus. 
A  careful  examination  shows  that  a  delicate  membrane  covers  the 
entire  maternal  surface,  unites  the  sulci  together,  and  dips  down  be- 
tween them.  This  is,  in  fact,  the  cellular  layer  of  the  decidua  serotma, 
which  is  separated  and  expelled  with  the  placenta,  the  deeper  layer 
remaining  attached  in  utero.  Numerous  small  openings  may  be 
seen  on  the  surface,  which  are  the  apertures  of  the  veins  torn  off 
from  the  uterus,  as  also  those  of  some  arteries,  which,  after  taking 
several  sharp  turns,  open  suddenly  into  the  substance  of  the  organ. 

Minute  Structure  of  the  Placenta. — As  regards  the  minute  structure 
of  the  placenta  it  is  certain  that  it  consists  essentially  of  two  dis- 
tinct portions,  one  foetal,  consisting  of  the  greatly  hypertrophied 
ehorionic  villi,  with  their  contained  vessels,  which  carry  the  foetal 
blood  so  as  to  bring  it  into  intimate  relation  with  the  maternal  blood, 
and  thus  admit  of  the  necessary  changes  occurring  in  it  connected 
with  the  nutrition  of  the  foetus;  and  the  other  maternal,  formed  out 
of  the  decidua  serotina  and  the  maternal  bloodvessels.  These  two 
portions  are  in  the  human  female  so  intimately  blended  as  to  form 
the  single  deciduous  organ  which  is  thrown  off'  after  delivery.  These 
main  facts  are  admitted  by  all,  but  considerable  differences  of  opinion 
still  exist  among  anatomists  as  to  the  precise  arrangement  of  these 
parts.  In  the  following  sketch  of  the  subject  I  shall  describe  the 
views  most  generally  entertained,  merely  briefly  indicating  the  points 
which  are  contested  by  various  authorities. 

Foetal  Portion  of  the  Placenta. — The  foetal  portion  of  the  placenta 
consists  essentially  of  the  ultimate  ramifications  of  the  chorion  villi, 
which  may  be  seen  on  microscopic  examination  in  the  form  of  club- 
shaped  digitations  which  are  given  off  at  every  possible  angle  from 
the  stem  of  a  parent  trunk,  just  like  the  branches  of  a  plant.  With- 
in the  transparent  walls  of  the  villi  the  capillary  tubes  of  the  con- 
tained vessels  may  be  seen  lying,  distended  with  blood,  and  present- 

COLLl£l£l£    Oi  IM=AT 

IHUSliMMils  >UL:O 


102 


PREGNANCY. 


ing  an  appearance  not  unlike  loops  of  small  intestine.  The  capilla- 
ries are  the  terminal  ramifications  of  the  umbilical  arteries  and  veins, 
which,  after  reaching  the  site  of  the  placenta,  divide  and  subdivide 
until  they  at  last  form  an  immense  number  of  minute  capillary 
vessels,  with  their  convexities  looking  towards  the  maternal  portion 
of  the  placenta,  each  terminal  loop  being  contained  in  one  of  the 
digitations  of  the  chorionic  villi.  Each  arterial  twig  is  accompanied 
by  a  corresponding  venous  branch,  which  unites  with  it  to  form  the 
terminal  arch  or  loop  (Fig.  55).  The  foetal  blood  is  carried  through 
these  arterial  twigs  to  the  villi,  where  it  comes  into  intimate  contact 


Placeutal  Villas,  greatly  magnified.     (After  Joulin.) 

1.  ".  Placental  vessels,  forming  terminal  loops.    3.  Choriou  tissue,  forming  external  walls  of  villas. 
4.  Tissue  surrounding  vessels. 

with  the  maternal  blood,  in  consequences  of  the  anatomical  arrange- 
ments presently  to  be  described ;  but  the  two  do  not  directly  mix,  as 
the  older  physiologists  believed,  for  none  of  the  maternal  blood 
escapes  when  the  umbilical  cord  is  cut,  nor  can  the  minutest  injections 
through  the  foetal  vessels  be  made  to  pass  into  the  maternal  vascular 
system,  or  vice  versa.  In  addition  to  the  looped  terminations  of  the 
umbilical  vessels,  Farre  and  Schroeder  van  der  Kolk  have  described 
another  set  of  capillary  vessels  in  connection  with  each  villus  (Fig. 
56).  This  consists  of  a  very  fine  network  covering  each  villus,  and 
very  different  in  appearance  from  the  convoluted  vessels  lying  in  its 
interior,  which  are  the  only  ones  which  have  been  usually  described. 
Dr.  Farre  believes  that  these  vessels  only  exist  in  the  early  months  of 

:  / 1  -5 1  E  \r  \j  K 


CONCEPTION    AND    GENERATION. 


103 


pregnancy,  and  that  they  disappear  as  pregnancy  advances.    Priestlev1 
suggests  that  they  may  not  be  vessels  at  al],  but  lymphatics,  which 


FIG.  56. 


a.  Terminal  villus  of  foetal  tuft,  minutely  injected.     6.  Its  nucleated  nonvascular  sheath.     (After 
F  arre.) 

rnay  possibly  absorb  nutrient  material  from  the  mother's  blood,  and 
throw  it  into  the  foetal  vascular  system.    The  existence  of  lymphatics, 

FIG.  57. 


Diagram  representing  a  Vertical  Section  of  the  Placenta.     (After  Daltou  ) 
a,  a.  Chorion.     6,  b.  Decidua.     c,  c,  c,  a.  Orifices  of  uterine  sinuses. 

or  nerves,  in  the  placenta,  however,  has  never  been  demonstrated, 
and  they  are  believed  not  to  exist. 

1  The  Gravid  Uterus,  p.  52. 


104 


PREGNANCY. 


Maternal  Portion  of  the  Placenta. — As  generally  described,  the 
maternal  portion  of  the  placenta  consists  of  large  cavities,  or  of  a 
single  large  cavity,  which,  contain  the  maternal  blood,  and  into  which 
the  villi  of  the  chorion  penetrate  (Fig.  57).  Into  this  maternal  part 
of  the  viscus  the  curling  arteries  of  the  uterus  pour  their  blood, 
which  is  collected  from  it  by  the  uterine  sinuses.  The  villi  of  the 
chorion,  therefore,  are  suspended  in  a  sac  rilled  with  maternal  blood, 
which  penetrates  freely  between  them,  and  with  which  they  are 
brought  into  very  intimate  contact.  Dr.  John  Eeid  believed  that 
only  the  delicate  internal  lining  of  the  maternal  vessels  entered  the 
substance  of  the  placenta,  to  form  the  sac  just  spoken  of.  Into  this 
the  villi  project,  pushing  before  them  the  membrane  forming  the 
limiting  wall  of  the  placental  sinuses,  each  of  them  in  this  way 
receiving  an  investment,  just  as  the  lingers  of  a  hand  are  covered  by 
a  glove  (Fig.  58). 


FIG.  58. 


FIG.  59. 


Diagram  illustrating  the  mode  in  which  a  pla- 
ceutal  villus  derives  a  covering  from  the  vascu- 
lar system  of  the  mother.  (After  Priestley.) 

a.  Villus  having  three  terminal  digitations  pro- 
jecting into  6.  Csivity  of  the  mother's  vessel,  c. 
Dotted  lines  representing  coat  of  vessel. 


The  Extremity  of  a  Placental  Villus. 
(After  Goodsir.) 

a.  External  membrane  of  villus  (the  lining 
membrane  of  vascular  system  of  Weber). 

ft.  External  cells  of  villus  derived  from 
decidua. 

e,  c.  Nuclei  of  ditto. 

d.  The  space  between  the  maternal  and 
foetal  portions  of  villus. 

e.  Its  internal  membrane. 

f.  Its  internal  cells. 

g.  The  loop  of  umbilical  vessels. 


Theory  of  Goodsir. — Schroeder  van  der  Kolk  and  Goodsir  (Fig.  59) 
were  of  opinion  that  not  only  were  the  maternal  bloodvessels  con- 
tinned  into  the  substance  of  the  placenta,  but  also  the  processes  of 
the  decidua,  which  accompanied  the  vessels  and  were  prolonged  over 
each  villus,  so  as  to  separate  it  from  the  limiting  membrane  of  the 
maternal  sinuses.  Each  villus  would  thus  be  covered  by  two  layers 
of  fine  tissue,  one  from  the  internal  lining  membrane  of  the  maternal 
bloodvessels,  the  other  from  the  epithelial  cells  of  the  decidua. 

Theory  of  Turner. — Turner,  whose  valuable  researches  on  the  com- 
parative anatomy  of  the  placenta  have  thrown  much  light  on  its 
structure,  points  out  that  the  placentae  of  all  animals  are  formed  on 
the. same  fundamental  type,1  in  which  the  foetal  portion  consists  of  a 
smooth,  plane-surfaced  vascular  membrane,  covered  with  pavement 


1  Introduction  to  Human  Anatomy,  part  2. 


CONCEPTION    AND    GENERATION.  105 

epithelium,  which  is  brought  into  contact  with  the  maternal  portion, 
consisting  of  a  smooth,  plane-surfaced  vascular  membrane,  covered 
with  columnar  epithelium.  The  foetal  capillaries  arc  separated  from 
the  maternal  capillaries  only  by  two  opposed  layers  of  epithelium. 
In  various  animals  the  placentse  are  more  or  less  specialized  from 
the  generalized  form,  in  some  to  a  much  greater  extent  than  others. 
In  the  human  placenta  the  maternal  vessels  have  lost  their  normal 
cylindrical  form,  and  are  dilated  into  a  system  of  freely  inter-com- 
municating placental  sinuses,  which  are,  in  fact,  maternal  capillaries 
enormously  enlarged,  with  their  walls  so  expanded  and  thinned  out 
that  they  cannot  be  recognized  as  a  distinct  layer  limiting  the  sinus. 
Each  foetal  chorionic  villus  projecting  into  these  sinuses  is  covered 
with  a  layer  of  cells  distinct  from  those  of  the  epithelial  layer  of  the 
villus,  and  readily  stripped  from  it.  These  are  maternal  in  their 
origin,  and  are  derived  from  the  decidua,  which  sends  prolongations 
of  its  tissue  into  the  placenta.  These  cells,  he  believes,  form  a  secret- 
ing epithelium  which  separates  from  the  maternal  blood  a  secretion 
for  the  nourishment  of  the  foetus,  which  is,  in  its  turn,  absorbed  by 
the  villi  of  the  chorion. 

Tlieory  of  Ercolani. — A  view  not  very  dissimilar  to  this  has  been 
advanced  by  Professor  Ercolani  of  Bologna,  who  maintains  that  the 
maternal  portion  of  the  placenta  is  a  new  formation,  strictly  glandu- 
lar, and  not  vascular,  in  its  structure.  It  is  formed,  he  thinks,  by 
the  submucous  connective  tissue -of  the  decidua  serotina,  and  it  dips 
down  into  the  placenta  and  forms  a  sheath  to  each  of  the  chorion 
villi,  which  it  separates  from  the  maternal  blood.  This  new  glandu- 
lar structure  he  describes  as  secreting  a  fluid,  termed  the  "  uterine 
milk,"  which  is  absorbed  by  the  villi  of  the  chorion,  just  as  the 
mother's  milk  is  absorbed  by  the  villi  of  the  intestines,  and  it  is  with 
this  fluid  alone  that  the  chorion  villi  are  in  direct  contact.  The  sheath 
thus  formed  to  each  villus  is  doubtless  analogous  to  the  layer  of  cells 
which  Goodsir  described  as  encasing  each  villus,  but  is  attributed  to 
a  new  structure  formed  after  conception. 

Theory  of  Braxton  Hicks. — The  existence  of  the  maternal  sinus 
system  in  the  placenta,  is  altogether  denied  by  anatomists  of  emi- 
nence whose  views  are  worthy  of  careful  consideration.  Prominent 
amongst  these  is  Braxton  Hicks,1  who  has  written  an  elaborate  paper 
on  the  subject.  He  holds  that  there  is  no  evidence  to  prove  that  the 
maternal  blood  is  poured  out  into  a  cavity  in  which  the  chorion  villi 
float,  and  he  believes  that  the  curling  arteries,  instead  of  entering 
the  so-called  maternal  portion  of  the  placenta,  terminate  in  the  deci- 
dua serotina.  The  hypertrophied  chorion  villi  at  the  site  of  the 
placenta  are  firmly  attached  to  the  decidual  surface,  into  which  their 
tips  are  embedded.  The  line  of  junction  between  the  decidua  reflexa 
and  serotina  forms  a  circumferential  margin  to,  and  limits  the  pla- 
centa. The  arrangement  of  the  foetal  portion  of  the  placenta  on  this 
view  is  very,  similar  to  that  generally  described,  but  the  villi  are  not 
surrounded  by  maternal  blood  at  all,  and  nothing  exists  between 

1  Obst.  Trans.,  vol.  xiv. 


106  PREGNANCY. 

them,  unless  it  be  a  small  quantity  of  serous  fluid.  The  change  in 
the  foetal  blood  is  effected  by  endosmosis,  and  Hicks  suggests  that 
follicles  of  the  decidua  may  secrete  a  fluid,  which  is  poured  into  the 
intervillous  spaces  for  absorption  by  the  villi. 

Functions  of  the  Placenta. — It  will  thus  be  seen  that  anatomists  of 
repute  are  still  undecided  as  to  important  points  in  the  minute  ana- 
tomy of  the  placenta,  which  further  investigation  will  doubtless 
clear  up.  The  main  functions  of  the  organ  are,  however,  sufficiently 
clear.  During  the  entire  period  of  its  existence  it  fills  the  important 
office  of  both  stomach  and  lungs  to  the  foetus.  Whatever  view  of 
the  arrangement  of  the  maternal  bloodvessels  be  taken,  it  is  certain 
that  the  fcetal  blood  is  propelled  by  the  pulsations  of  the  foetal  heart 
into  the  numberless  villi  of  the  chorion,  where  it  is  brought  into 
very  intimate  relation  with  the  mother's  blood,  gives  off'  its  carbonic 
acid,  absorbs  oxygen,  and  passes  back  to  the  foetus,  through  the  um- 
bilical veins,  in  a  fit  state  for  circulation.  The  mode  of  respiration, 
therefore,  in  the  foetus  is  analogous  to  that  in  fishes,  the  chorion  villi 
representing  the  gills,  the  maternal  blood  the  water  in  which  they 
float.  Nutrition  is  also  effected  in  the  organ,  and,  by  absorption 
through  the  chorion  villi,  the  pabulum  for  the  nourishment  of  the 
foetus  is  taken  up.  It  also  probably  serves  as  an  emunctory  for  the 
products  of  excretion  in  the  foetus.  Picard  found  that  the  blood  in 
the  placenta  contained  an  appreciably  larger  quantity  of  urea  than 
that  in  other  parts  of  the  body,  this  urea  probably  being  derived 
from  the  foetus.  Claude  Bernard  also  attributed  to  it  a  glycogenic 
function,1  supposing  it  to  take  the  place  of  the  foetal  liver  until  that 
organ  was  sufficiently  developed. 

Degenerative  Changes  previous  to  Expulsion. — Finally,  we  find  that 
the  temporary  character  of  the  placenta  is  indicated  by  certain  degen- 
erative changes,  which  take  place  in  it  previous  to  expulsion.  These 
consist  chiefly  in  the  deposit  of  calcareous  patches  on  its  uterine  sur- 
face, and  in  fatty  degeneration  of  the  villi,  and  of  the  decidual  layer 
between  the  placenta  and  the  uterus.  If  this  degeneration  be  carried 
to  excess,  as  is  not  unfrequently  the  case,  the  foetus  may  perish  from 
a  want  of  a  sufficient  number  of  healthy  villi  through  which  its 
respiration  and  nutrition  may  be  effected. 

Umbilical  Cord. — The  umbilical  cord  is  the  channel  of  communi- 
cation between  the  foetus  and  placenta,  being  attached  to  the  former 
at  the  umbilicus,  to  the  latter  generally  near  its  centre,  but  some- 
times, as  in  the  battledore  placenta,  at  its  edge.  It  varies  much  in 
length,  measuring  on  an  average  from  18  to  24  inches,  but  in  excep- 
tional cases  being  found  as  long  as  50  or  60,  and  as  short  as  5  or  6 
inches. 

When  fully  formed  it  consists  of  an  external  membranous  layer 
formed  of  the  amnion,  two  umbilical  arteries,  one  umbilical  vein,  and 
a  considerable  quantity  of  transparent  gelatinous  substance  surround- 
ing the  vessels,  called  Wharton's  jelly,  which  is  contained  in  a  fine 
network  of  fibres,  and  is  formed  out  of  the  tissue  of  the  allantois. 

1  Acad.  des  Sciences,  April,  1859. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS. 

At  an  early  period  of  pregnancy,  in  addition  to  these  structures,  the 
cord  contains  the  pedicle  of  the  umbilical  vesicle,  with  the  omphalo- 
mesenteric  vessels  ramifying  on  it,  and  two  umbilical  veins,  one  of 
which  soon  atrophies  and  disappears.  No  nerves  or  lymphatics  have 
been  satisfactorily  demonstrated  in  the  cord,  although  such  have 
been  described  as  existing.  The  vessels  of  the  cord  are  at  first 
straight  in  their  course,  but  shortly  they  become  greatly  twisted,  the 
arteries  being  external  to  the  vein,  and  in  nine  cases  out  of  ten  the 
twist  is  from  left  to  right.  Various  explanations  have  been  given  of 
this  peculiarity,  none  of  them  entirely  satisfactory.  Tyler  Smith 
attributed  it  to  the  movements  of  the  foetus  twisting  the  cord,  its 
attachment  to  the  placenta  being  a  fixed  point ;  this  would  not,  how- 
ever, account  for  the  frequency  with  which  the  spiral  turns  occur  in 
one  direction.  Mr.  John  Simpson  attributed  it  to  the  greater  pres- 
sure of  the  blood  through  the  right  hypogastric  artery,  on  account 
of  that  vessel  having  a  more  direct  relation  to  the  aorta  than  the 
left.  The  umbilical  arteries  give  off  no  branches,  and  the  vein  con- 
tains no  valves,  nor  can  any  vasa  vasorum  be  detected  in  their  coats 
after  they  have  left  the  umbilicus.  The  umbilical  arteries  increase 
in  size  after  they  leave  the  cord,  to  divide  on  the  surface  of  the  pla- 
centa. This  is  the  only  example  in  the  body  in  which  arteries  are 
larger  near  their  terminations  than  their  origin,  and  the  object  of 
this  arrangement  is  probably  to  effect  a  retardation  of  the  current  of 
the  blood  distributed  to  the  placenta.  The  tortuous  course  of  the 
vein  probably  compensates  for  the  absence  of  valves,  and  moderates 
the  flow  of  blood  through  it.  Distinct  knots  are  not  unfrequently 
observed  in  the  cord,  but  they  rarely  have  the  effect  of  obstructing 
the  circulation  through  it.  They  no  doubt  form  when  the  foetus  is 
very  small.  They  may  sometimes  also  be  produced  in  labor  by  the 
child  being  propelled  through  a  coil  of  the  cord  lying  circularly  round 
the  os  uteri.  The  so-called  false  knots  are  merely  accidental  nodosi- 
ties due  to  local  enlargements  of  the  vessels. 


CHAPTER  11. 

THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  F(ETUS. 

IT  is  obviously  impossible  to  attempt  anything  like  a  full  account 
of  the  development  of  the  various  foetal  structures,  or  of  their  growth 
during  intra-uterine  life.  To  do  so  would  lead  us  far  beyond  the 
scope  of  this  work,  and  would  involve  a  study  of  complex  details 
only  suitable  in  a  treatise  on  Embryology.  It  is  of  importance,  how- 
ever, that  the  practitioner  should  have  it  in  his  power  to  determine 
approximatively  the  age  of  the  foetus  in  abortions  or  premature 


108  PREGNANCY. 

labor,  and  for  this  purpose  it  is  necessar}*-  to  describe  briefly  the  ap- 
pearance of  the  foetus  at  various  stages  of  its  growth. 

1st  Month. — The  foetus  in  the  first  month  of  gestation  is  a  minute 
gelatinous,  and  semi-transparent  mass,  of  a  grayish  color,  in  which 
no  definite  structure  can  be  made  out.  and  in  which  no  head  nor  ex- 
tremities can  be  seen.  It  is  rarely  to  be  detected  in  abortions,  being 
lost  in  surrounding  blood  clots.  In  the  few  examples  which  have 
been  carefully  examined  it  did  not  measure  more  than  a  line  in  length. 
It  is  however,  already  surrounded  by  the  amnion,  and  the  pedicle 
of  the  umbilical  vesicle  can  be  traced  into  the  unclosed  abdominal 
cavity. 

2d  Month. — The  embryo  becomes  more  distinctly  apparent,  and  is 
curved  on  itself,  weighing  about  62  grains,  and  measuring  6  or  8 
lines  in  length.  The  head  and  extremities  are  distinctly  visible — • 
the  latter  in  the  form  of  rudimentary  projections  from  the  body. 
The  eyes  are  to  be  seen  as  small  black  spots  on  the  side  of  the  head. 
The  spinal  column  is  divided  into  separate  vertebras.  The  indepen- 
dent circulatory  system  of  the  foetus  is  now  beginning  to  form,  the 
heart  consisting  of  only  one  ventricle  and  one  auricle,  from  the 
former  of  which  both  the  aorta  and  pulmonary  arteries  arise.  On 
either  side  of  the  vertebral  column,  reaching  from  the  heart  to  the 
pelvis,  are  two  large  glandular  structures,  the  corpora  Wolffiania, 
which  consist  of  a  series  of  convoluted  tub«s  opening  into  an  excre- 
tory duct,  running  along  their  external  borders,  and  connected  below 
with  the  common  cloaca  of  the  genito-urinary  and  digestive  tracts. 
They  seem  to  act  as  secreting  glands,  and  fulfil  the  functions  of  the 
kidneys  before  these  are  formed.  Towards  the  end  of  the  second 
month  they  atrophy  and  disappear,  and  the  only  trace  of  them  in 
the  foetus  at  term  is  to  be  found  in  the  parovarium  tying  between 
the  folds  of  the  broad  ligaments.  At  this  stage  of  development 
there  are  met  with  in  the  human  embryo,  as  in  that  of  all  mammals, 
four  transverse  fissures  opening  into  the  pharynx,  which  are  analo- 
gous to  the  permanent  branchiae  of  fishes.  Their  vascular  supply  is 
also  similar,  as  the  aorta  at  this  time  gives  off  four  branches  on  each 
side,  each  of  which  forms  a  branchial  arch,  and  these  afterwards 
unite  to  form  the  descending  aorta.  By  the  end  of  the  sixth  week 
these,  as  well  as  the  transverse  fissures  to  which  they  are  distributed, 
disappear.  By  the  end  of  the  second  month  the  kidneys  and  supra- 
renal capsules  are  forming,  and  the  single  ventricle  is  divided  into 
two  by  the  growth  of  the  inter-ventricular  septum.  The  umbilical 
cord  is  quite  straight,  and  is  inserted  into  the  lower  part  of  the  ab- 
domen. Centres  of  ossification  are  showing  themselves  in  the  infe- 
rior maxillary  bones  and  the  clavicle. 

3d  Month. — The  embryo  weighs  from  70  to  300  grains,  and  meas- 
ures from  2|  to  3^  inches  in  length.  The  forearm  is  well  formed 
and  the  first  traces  of  the  fingers  can  be  made  out.  The  head  is 
large  in  proportion  to  the  rest  of  the  body,  and  the  eyes  are  promi- 
nent. The  umbilical  vesicle  and  allantois  have  disappeared,  the 
greater  portion  of  the  chorion  villi  have  atrophied,  and  the  placenta 
is  distinctly  formed. 


ANATOMY    AND    PHYSIOLOGY    OP    THE    FCETUS.  109 

4th  Month. — The  weight  is  from  -1  to  6  oz.,  and  the  length  about  6 
inches.  The  convolutions  of  the  brain  are  beginning  to  develop. 
The  sex  of  the  child  can  now  be  ascertained  on  inspection.  The 
muscles  are  sufficiently  formed  to  produce  distinct  movements  of  the 
limbs.  Ossification  is  extending,  and  can  be  traced  in  the  occipital 
and  frontal  bones,  and  in  the  mastoid  processes.  The  sexual  organs 
are  differentiated, 

5th  Month. — Weight  about  10  oz.  Length,  9  or  10  inches.  Hair 
is  observed  covering  the  head,  which  forms  about  one-third  of  the 
length  of  the  whole  foetus.  The  nails  are  beginning  to  form,  and 
ossification  has  commenced  in  the  ischiurn. 

6th  Month— Weight  about  1  Ib.  Length,  11  to  12J  inches.  The 
hair  is  darker.  The  eyelids  are  closed,  and  the  membrana  pupillaris 
exists ;  eyelashes  have  now  been  formed.  Some  fat  is  deposited 
under  the  skin.  The  testicles  are  still  in  the  abdominal  cavity.  The 
clitoris  is  prominent.  The  pubic  bones  have  begun  to  ossify. 

7th  Month. — Weight,  from  3  to  4  Ibs.  Length,  13  to  15  inches. 
The  skin  is  covered  with  unctuous,  sebaceous  matter,  and  there  is  a 
more  considerable  deposit  of  sub-cutaneous  fat.  The  eyelids  are 
open.  The  testicles  have  descended  into  the  scrotum. 

8th  Month. — Weight,  from  4  to  5  Ibs.  Length,  16  to  18  inches ; 
and  the  foetus  seems  now  to  grow  in  thickness  rather  than  in  length. 
The  nails  are  completely,  developed.  The  membrana  pupillaris  has 
disappeared. 

foetus  at  Term. — At  the  completion  of  pregnancy  the  foetus  weighs 
on  an  average  6  J  Ibs.,  and  measures  about  20  inches  in  length.  These 
averages  are,  however,  liable  to  great  variation.  Eemarkable  his- 
tories are  given  by  many  writers  of  foetuses  of  extraordinary  weight, 
which  have  been  probably  greatly  exaggerated.  Out  of  3000  children 
delivered  under  the  care  of  Cazeaux  at  various  charities,  one  only 
weighed  10  Ibs.  There  are,  however- -.several  carefully  recorded 
instances  of  weight  far  exceeding  this';  tnit  they  are  undoubtedly 
much  more  uncommon  than  is  generally  supposed.  Dr.  Kamsbotham 
mentions  a  foetus  weighing  16£  Ibs.,  and  Cazeaux  tells  of  one  which 
he  delivered  by  turning  which  weighed  18  Ibs.,  and  measured  2  feet 
1J  inches.  Such  overgrown  children  are  almost  invariably  stillborn. 
On  the  other  hand,  mature  children  have  been  born  and  survived 
which  have  not  weighed  more  than  5  Ibs.  [2|  lbs.: — ED.] 

The  average  size  of  male  children  at  birth,  as  in  after  life,  is  some- 
what greater  than  that  of  female.  Thus  Simpson1  found  that  out  of 
100  cases  the  male  children  averaged  10  oz.  more  in  weight  than  the 
female,  and  J  an  inch  more  in  length.  A  new-born  child  at  term  is 
generally  covered  to  a  greater  or  less  extent  with  a  greasy,  unctuous 
material,  the  vernix  caseosa,  which  is  formed  of  epithelial  scales  and 
the  secretion  of  the  sebaceous  glands,  and  which  is  said  to  be  of  use 
in  labor,  by  lubricating  the  surface  of  the  child.  The  head  is  gene- 
rally povered  with  long  dark  hair,  which  frequently  falls  off  or  changes 
in  color  shortly  after  birth.  Dr.  Wiltshire2  has  called  attention  to 

1  Selected  Obst.  Works,  p.  327.  2  Lancet,  February  11,  1871. 


110  PREGNANCY. 

an  old  observation,  that  the  eyes  of  all  new-born  children  are  of  a 
peculiar  dark  steel-gray  color,  and  that  they  do  not  acquire  their 
permanent  tint  until  some  time  after  birth.  The  umbilical  cord  is 
generally  inserted  below  the  centre  of  the  body. 

Anatomy  of  the  Foetal  Head. — The  most  important  part  of  the 
foetus  from  an  obstetrical  point  of  view  is  the  head,  which  requires  a 
separate  study,  as  it  is  the  usual  presenting  part,  and  the  facility  of 
the  labor  depends  on  its  accurate  adaptation  to  the  maternal  passages. 

The  chief  anatomical  peculiarity  of  interest,  in  the  head  of  the 
foetus  at  term,  is  that  the  bones  of  the  skull,  especially  of  its  vertex — 
which,  in  the  vast  majority  of  cases,  has  to  pass  first  through  the 
pelvis — are  not  firmly  ossified  as  in  adult  life,  but  are  joined  loosely 
together  by  membrane  or  cartilage.  The  result  of  this  is,  that  the 
skull  is  capable  of  being  moulded  and  altered  in  form  to  a  very  con- 
siderable extent  by  the  pressure  to  which  it  is  subjected,  and  thus  its 
passage  through  the  pelvis  is  very  greatly  facilitated.  This,  however, 
is  chiefly  the  case  with  the  cranium  proper,  the  bones  of  the  face  and 
of  the  base  of  the  skull  being  more  firmly  united.  By  this  means 
the  delicate  structures  at  the  base  of  the  brain  are  protected  from 
pressure,  while  the  change  of  form  which  the  skull  undergoes  during 
labor  implicates  a  portion  of  the  skull  where  pressure  on  the  cranial 
contents  is  least  likely  to  be  injurious. 

The  divisions  between  the  bones  of  the  cranium  are  further  of 
obstetric  importance  in  enabling  us  to  detect  the  precise  position  of 
the  head  during  labor,  and  an  accurate  knowledge  of  them  is  there- 
fore essential  to  the  obstetrician. 

The  /Sutures  and  Fontanelles. — We  talk  of  them  as  sutures  and 
fontanelles,  the  former  being  the  lines  of  junction  between  the  sepa- 
rate bones  which  overlap  each  other  to  a  greater  or  less  extent  during 
labor ;  the  latter  membranous  interspaces  where  the  sutures  join  each 
other. 

The  principal  sutures  are :  1st,  the  sagittal,  which  separates  the 
two  parietal  bones,  and  extends  longitudinally  backwards  along  the 
vertex  of  the  head.  2d.  The  frontal,  which  is  a  continuation  of  the 
sagittal,  and  divides  the  two  halves  of  the  frontal  bone,  at  this  time 
separate  from  each  other.  3d.  The  coronal,  which  separates  the 
frontal  from  the  parietal  bones,  and  extends  from  the  squamous  por- 
tion of  the  temporal  bone  across  the  head  to  a  corresponding  point 
on  the  opposite  side;  and  4th,  the  lambdoidal,  which  receives  its 
name  from  its  resemblance  to  the  Greek  letter  A,  and  separates  the 
occipital  from  the  parietal  bones  on  either  side.  The  fontanelles 
(Fig.  60)  are  the  membranous  interspaces  where  the  sutures  join — 
the  anterior  and  larger  being  lozenge-shaped,  and  formed  by  the  junc- 
tion of  the  frontal,  sagittal,  and  two  halves  of  the  coronal  sutures. 
It  will  be  well  to  note  that  there  are,  therefore,  four  lines  of  sutures 
running  into  it,  and  four  angles,  of  which  the  anterior,  formed  by 
the  frontal  suture,  is  most  elongated  and  well  marked.  The  posterior 
fontanelle  (Fig.  61)  is  formed  by  the  junction  of  the  sagittal  suture 
with  the  two  legs  of  the  lambdoidal.  It  is,  therefore,  triangular  in 
shape,  with  three  lines  of  suture  entering  it  in  three  angles,  and  is 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS. 


Ill 


much  smaller  than  the  anterior  fontanelle,  forming  merely  a  depres- 
sion into  which  the  tip  of  the  linger  can  be  placed,  while  the  latter  is 
a  hollow  as  big  as  a  shilling,  or  even  larger.  As  it  is  the  posterior 
fontanelle  which  is  generally  lowest,  and  the  one  most  commonly  felt 


FIG.  CO. 


FIG.  Gl. 


Anterior  and  Posterior  Fontanelles. 


Bi-parietal  Diameter,  Sagittal  and  Lambdoidal 
Sutures,  with.  Posterior  Fontanelles. 


FIG.  62. 


during  labor,  it  is  important  for  the  student  to  familiarize  himself 
with  it,  and  he  should  lose  no  opportunity  of  studying  the  sensations 
imparted  to  the  finger  by  the  sutures  and  fontanelles  in  the  head  of 
the  child  after  birth. 

The  Diameters  of  the  Foetal  Skull. — For  the  purpose  of  understand- 
ing the  mechanism  of  labor,  we  must  study  the  measurements  of  the 
foetal  head  in  relation  to  the  cavi- 
ty through  which  it  has  to  pass. 
They  are  taken  from  correspond- 
ing points  opposite  to  each  other, 
arid  are  known  as  the  diameters 
of  the  skull  (Fig.  62).  Those  of 
most  importance  are :  1st.  The 
occipito-mental,  from  the  occipital 
protuberance  to  the  point  of  the 
chin,  5.25"  to  5.50".  2d.  The  oc- 
cipito-frontal,  from  the  occiput  to 
the  centre  of  the  forehead,  4.50" 
to  5".  3d.  The  sub-occipito-breg- 
matic,  from  a  point  midway  be- 
tween the  occipital  protuberance 
and  the  margin  of  the  foramen 
magnum  to  the  centre  of  the  an- 
terior fontanelle,  3.25".  4th.  The 
cervico-bregmatic,  from  the  anterior  margin  of  the  foramen  magnum 
to  the  centre  of  the  anterior  fontanelle,  3.75".  5th.  Transverse  or 
Id-parietal,  between  the  parietal  protuberances,  3.75"  to  4".  6th.  Bi- 
temporal,  between  the  ears,  3.50".  7th.  Fr  onto -mental,  from  the  apex 
of  the  forehead  to  the  chin,  3.25". 


1  &  2.  Occipito-frontal  diameter. 

3  &  4.  Occipito-mental. 

5  &  6.  Cervico-bregmatic. 

7  &  8.  Fronto-mental. 


112  PREGNANCY. 

Alteration  of  Diameter  during  Labor. — The  length  of  these  respec- 
tive diameters,  as  given  by  different  writers,  differs  considerably — 
a  fact  to  be  explained  by  the  measurements  having  been  taken  at 
different  times;  by  some  just  after  birth,  when  the  head  was  altered 
in  shape  by  the  moulding  it  had  undergone ;  by  others  when  this 
had  either  been  slight,  or  after  the  head  had  recovered  its  normal 
shape.  The  above  measurements  may  be  taken  as  the  average  of 
those  of  the  normally-shaped  head,  and  it  is  to  be  noted  that  the  first 
two  are  most  apt  to  be  modified  during  labor.  The  amount  of  com- 
pression and  moulding  to  which  the  head  may  be  subjected,  without 
proving  fatal  to  the  foetus,  is  not  certainly  known,  but  it  is  doubtless 
very  considerable.  Some  interesting  examples  of  the  extent  to  which 
the  head  may  be  altered  in  shape  in  difficult  labors  have  been  given 
by  Barnes,1  who  has  shown,  by  tracings  of  the  shape  of  the  head 
taken  immediately  after  delivery,  that  in  protracted  labor  the  oc- 
cipito-mental  and  occipito-frontal  diameters  may  be  increased  more 
than  an  inch  in  length,  while  lateral  compression  may  diminish  the 
bi-parietal  diameter  to  the  same  length  as  the  inter-auricular.  The 
fcetal  head  is  movable  on  the  vertical  column  to  the  extent  of  a 
quarter  of  a  circle;  and  it  seems  probable  that  the  laxity  of  the  liga- 
ments admits  with  impunity  a  greater  circular  movement  than  would 
be  possible  in  the  adult. 

Influence  of  Sex  and  Race  on  the  Fcetal  Head. — On  taking  the  ave- 
rage of  a  large  number  of  measurements,  it  is  found  that  the  heads 
of  male  children  are  larger  and  more  firmly  ossified  than  those  of 
females,  the  former  averaging  about  half  an  inch  more  in  circum- 
ference. Sir  James  Simpson  attributed  great  importance  to  this  fact, 
and  believed  that  it  was  sufficient  to  account  for  the  larger  proportion 
of  still  births  in  male  than  in  female  children,  as  well  as  for  the  greater 
difficulty  of  labor  and  the  increased  maternal  mortality  that  are  found 
to  attend  on  male  births.  His  well-known  paper  on  this  subject, 
which  has  given  rise  to  much  controversy,  is  full  of  the  most  elaborate 
details,  and  so  great  did  he  believe  the  fcetal  influence  to  be,  that  he 
calculated  that  between  the  years  1834  and  1837  there  were  lost  in 
Great  Britain,  as  a  consequence  of  the  slightly  larger  size  of  the  male 
than  of  the  female  head  at  birth,  about  50,000  lives,  including  those 
of  about  46,000  or  47,000  infants,  and  of  between  3000  and  4000 
mothers  who  died  in  childbed.2  It  is  probable  that  race  and  other 
conditions,  such  as  civilization  and  intellectual  culture,  have  con- 
siderable influence  on  the  size  of  the  fcetal  skull,  but  we  are  not  in 
possession  of  sufficiently  accurate  data  to  justify  any  very  positive 
opinion  on  these  points.  -*^" 

Position  of  the  foetus  in\7tero. — In  the  very  large  majority  of  cases 
the  foetus  lies  in  utero  with  the  head  downwards,  and  is  so  placed  as 
to  be  adapted  in  the  most  convenient  way  to  the  cavity  in  which  it 
is  placed.  The  uterine  cavity  is  most  roomy  at  the  fundus,  and 
narrowest  at  the  cervix,  and  the  greatest  bulk  of  the  foetus  is  at  the 
breech,  so  that  the  largest  part  of  the  child  usually  lies  in  the  part 

1  Obst.  Trans.,  vol.  vii.  «  Selected  Obstet.  Works,  p.  363. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.  113 

of  the  uterus  best  adapted  to  contain  it.  The  various  parts  of  the 
child's  body  are  further  so  placed,  in  regard  to  each  other,  as  to  take 
up  the  least  possible  amount  of  space.  (See  frontispiece.)  The  body 
is  bent  so  that  the  spine  is  curved  with  its  convexity  outwards,  this 
curvature  existing  from  the  earliest  period  of  development;  the  chin 
is  flexed  on  the  sternum;  the  forearms  are  flexed  on  the  arms,  and 
lie  close  together  on  the  front  of  the  chest-;  the  legs  are  flexed  on 
the  thighs,  and  the  thighs  drawn  up  on  the  abdomen;  the  feet  are 
drawn  up  towards  the  leg;  the  umbilical  cord  is  generally  placed 
out  of  reach  of  injurious  pressure,  in  the  space  between  the  arms 
and  the  thighs.  Variations  from  this  attitude,  however,  are  not 
uncommon,  and  are  not,  as  a  rule,  of  much  consequence.  Although 
the  cranial  presentations  are  much  the  most  common,  averaging  96 
out  of  every  100  cases,  other  presentations  are  by  no  means  rare,  the 
next  most  frequent  being  either  that  of  the  breech,  in  which  the  long 
diameter  of  the  child  lies  in  the  long  diameter  of  the  uterine  cavity, 
or  some  variety  of  transverse  presentation,  in  which  the  long  dia- 
meter of  the  foetus  lies  obliquely  across  the  uterus,  and  no  longer 
corresponds  to  its  longitudinal  axis. 

Changes  of  Foetal  Position  during  Pregnancy. — It  was  long  believed 
that  the  head  presentation  was  only  assumed  towards  the  end  of 
pregnancy,  when  it  was  supposed  to  be  produced  by  a  sudden  move- 
ment on  the  part  of  the  foetus,  known  as  the  culbute.  It  is  now  well 
known  that,  in  the  large  majority  of  cases,  the  head  is  lowest  during 
all  the  latter  part  of  pregnancy,  although  changes  in  position  are 
more  common  than  is  generally  believed  to  be  the  case,  and  presen- 
tation of  parts  other  than  the  head  is  much  more  frequent  in  pre- 
mature labor  than  in  delivery  at  term.  In  evidence  of  the  last 
statement,  Churchill  says  that  in  labor  at  the  seventh  month  the 
head  presents  only  83  times  out  of  100  when  the  child  is  living,  and 
that  as  many  as  53  per  cent,  of  the  presentations  are  preternatural 
when  the  child  is  still-born.  The  frequency  with  which  the  foetus 
changes  its  position  before  delivery  has  been  made  the  subject  of 
investigation  by  various  German  obstetricians,  and  the  fact  can  be 
readily  ascertained  by  examination.  Valenta1  found  that  out  of 
nearly  1000  cases,  carefully  and  frequently  examined  by  him,  in  57.6 
per  cent,  the  presentation  underwent  no  change  in  the  latter  months 
of  pregnancy,  but  in  the  remaining  42.4  per  cent,  a  change  could  be 
readily  detected.  These  alterations  were  found  to  be  most  frequent 
in  multipart,  and  the  tendency  was  for  abnormal  presentations  to 
alter  into  normal  ones.  Thus  it  was  common  for  transverse  presenta- 
tions to  alter  longitudinally,  and  but  rare  for  breech  presentations  to 
change  into  head.  The  ease  with  which  these  changes  are  effected 
no  doubt  depends,  in  a  considerable  degree,  on  the  laxity  of  the 
uterine  parietes,  and  on  the  greater  quantity  of  amniotic  fluid,  by 
both  of  which  the  free  mobility  of  the  foetus  is  favored. 

Detection  of  Foetal  Position  by  Abdominal  Palpation. — The  facility 
with  which  the  position  of  the  foetus  in  utero  can  be  ascertained  by 

1  Mon.  f.  Geburt.,  1866. 


114 


PREGNANCY 


abdominal  palpation  has  not  been  generally  appreciated  in  obstetric 
works,  and  yet,  by  a  little  practice,  it  is  easy  to  make  it  out.  Much 
information  of  importance  can  be  gained  in  this  way,  and  it  is  quite 
possible,  under  favorable  circumstances,  to  alter  abnormal  presen- 
tations before  labor  has  begun.  For  the  purpose  of  making  this 
examination,  the  patient  should  lie  at  the  edge  of  the  bed,  with  her 
shoulders  slightly  raised,  and  the  abdomen  uncovered.  The  first 
observation  to  make  is  to  see  if  the  longitudinal  axis  of  the  uterine 
tumor  corresponds  with  that  of  the  mother's  abdomen;  if  it  does,  the 
presentation  must  be  either  a  head  or  a  breech.  By  spreading  the 
hands  over  the  uterus  (Fig.  63),  a  greater  sense  of  resistance  can  be 

FIG.  63. 


Mode  of  ascertaining  the  Position  of  the  Foetus  by  Palpation. 

felt,  in  most  cases,  on  one  side  than  on  the  other,  corresponding  to 
the  back  of  the  child.  By  striking  the  tips  of  the  fingers  suddenly 
inwards  at  the  fundus,  the  hard  breech  can  generally  be  made  out, 
or  the  head,  still  more  easily,  if  the  breech  be  downwards.  When 
the  uterine  walls  are  unusually  lax,  it  is  often  possible  to  feel  the 
limbs  of  the  child.  These  observations  can  be  generally  corroborated 
by  auscultation,  for  in  head  presentations  the  foetal  heart  can  usually 
be  heard  below  the  umbilicus,  and  in  breech  cases  above  it.  Trans- 
verse presentations  can  even  more  easily  be  made  out  by  abdominal 
palpation.  Here  the  long  axis  of  the  uterine  tumor  does  not  corre- 
spond with  the  long  axis  of  the  mother's  abdomen,  but  lies  obliquely 
across  it.  By  palpation  the  rounded  mass  of  the  head  can  be  easily 
felt  in  one  of  the  mother's  flanks,  and  the  breech  in  the  other,  while 
the  foetal  heart  is  heard  pulsating  nearer  to  the  side  at  which  the 
head  is  detected. 

Explanation  of  the  Position  of  the  Foetus  in  Utero. — The  reason  why 
the  head  presents  so  frequently  has  been  made  the  subject  of  much 
discussion.  The  oldest  theory  was,  that  the  head  lay  over  the  os 


ANATOMY    AND    PHYSIOLOGY    OF    THE    F(ETUS. 


115 


uteri  as  the  result  of  gravitation,  and  the  influence  of  gravity,  although 
contested  by  many  obstetricians,  prominent  among  whom  were  Du- 
bois  and  Simpson,  has  been  insisted  upon  as  the  chief  cause  by  others, 
Dr.  Duncan  being  one  of  the  most  strenuous  advocates  of  this  view. 
The  objections  urged  against  the  gravitation  theory  were  drawn 
partly  from  the  result  of  experiments,  arid  partly  from  the  frequency 
with  which  abnormal  presentations  occurred  in  premature  labors, 
when  the  action  of  gravity  could  not  be  supposed  to  be  suspended. 
The  experiments  made  by  Dubois  went  to  show  that  when  a  foetus 
was  suspended  in  water  gravitation  caused  the  shoulders,  and  not 
the  head,  to  fall  lowest.  He,  therefore,  advanced  the  hypothesis  that 
the  position  of  the  foetus  was  due  to  instinctive  movements,  which  it 
made  to  adapt  itself  to  the  most  comfortable  position  in  which  it 
could  lie.  It  need  only  be  remarked  that  there  is  not  the  slightest 
evidence  of  the  foetus  possessing  any  such  power.  Simpson  proposed  a 
theory  which  was  much  more  plausible.  He  assumed  that  the  foetal 
position  was  due  to  reflex  movements  produced  by  physical  irrita- 
tions to  which  the  cutaneous  surface  of  the  foetus  is  subjected  from 
changes  of  the  mother's  position,  uterine  contractions,  and  the  like. 
The  absence  of  these  movements,  in  the  case  of  the  death  of  the  foetus, 
would  readily  explain  the  frequency  of  mal-presentation  under  such 
circumstances.  The  obvious  objection  to  this  theory,  complete  as  it 
seems  to  be,  is  the  absence  of  any  proof  that  such  constant  extensive 
reflex  movements  really  do  occur  in  utero.  Dr.  Duncan  has  very 
conclusively  disposed  of  the  principal  objections  which  have  been 


Diagram  illustrating  the  Effect  of  Gravity  on  the  Foetus.     (After  Duncan .) 

a,  6,  is  parallel  to  the  axis  of  the  pregnant  uterus  and  pelvic  brim,     o,  d,  e,  is  a  perpendicular  line. 
e,  the  centre  of  gravity  of  the  foetus,     d,  the  centre  of  flotation. 

raised  against  the  influence  of  gravitation,  and  when  an  obvious  ex- 
planation of  so  simple  a  kind  exists  it  seems  useless  to  seek  further 
for  another.  He  has  shown  that  Dubois'  experiments  did  not  accu- 
rately represent  the  state  of  the  foetus  in  utero,  and  that  during  the 


110  PHEGNANCY. 

greater  part  of  the  day,  when  the  woman  is  upright,  or  lying  on  her 
back,  the  foetus  lies  obliquely  to  the  horizon  at  an  angle  of  about  30°. 
The  child  thus  lies,  in  the  former  case,  on  an  inclined  plane,  formed 
by  the  anterior  uterine  wall  and  by  the  abdominal  parietes,  in  the 
latter  by  the  posterior  uterine  wall  and  the  vertebral  column.  Down 
the  inclined  plane  so  formed  the  force  of  gravity  causes  the  foetus 
to  slide,  and  it  is  only  when  the  woman  lies  on  her  side  that  the 
foetus  is  placed  horizontally,  and  is  not  subjected  in  the  same  degree 
to  the  action  of  gravity  (Fig.  6-i).  The  frequency  of  mal-presenta- 
tions  in  premature  labors  is  explained  by  Dr.  Duncan  partly  by  the 
fact  that  the  death  of  the  child  (which  so  frequently  precedes  such 
cases)  alters  its  centre  of  gravity,  and  partly  by  the  greater  mobil- 
ity of  the  child  and  the  greater  relative  amount  of  liquor  amnii 
(Fig.  65).  The  influence  of  gravitation  is  probably  greatly  assisted 

FIG.  65. 


Illustrating  the  greater   Mobility  of  the  Foetus  and   the  Larger  relative  Amount  of  Liquor  Amuii  in 

Early  Pregnancy.     (After  Duncan.) 
a,  b.  Axis  of  pregnant  uterus.  b,  h.  A  horizontal  line. 

by  the  contractions  of  the  uterus  which  are  going  on  during  the 
greater  part  of  pregnancy.  The  influence  of  these  was  pointed  out 
by  Dr.  Tyler  Smith,  who  distinctly  showed  that  the  contractions  of 
the  uterus  preceding  delivery  exerted  a  moulding  or  adapting  influ- 
ence on  the  foetus,  and  prevented  undue  alterations  of  its  position. 
Dr.  Hicks  proved1  that  these  uterine  contractions  are  of  constant 
occurrence  from  the  earliest  period  of  pregnancy,  and  there  can  be 
little  doubt  that  they  must  have  an  important  influence  on  the  body 
contained  within  the  uterus. 

Functions  of  the  Foetus. — The  functions  of  the  foetus  are  in  the 
main  the  same,  with  differences  depending  on  the  situation  in  which 
it  is  placed,  as  those  of  the  separate  being.  It  breathes,  it  is 
nourished,  it  forms  secretions,  and  its  nervous  system  acts.  The 
mode  in  which  some  of  these  functions  are  carried  on  in  intra-uterine 
life  requires  separate  consideration. 

1.  Nutrition. — During  the  early  period  of  pregnancy,  and  before 
the  formation  of  the  umbilical  vesicle  and  the  allantois,  it  is  certain 

1  Obst.  Trans,  vol.  xiii.  p.  216. 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS.  117 

that  nutritive  material  must  be  supplied  to  the  ovum  by  endosmosis 
through  its  external  envelope.  The  precise  source,  however,  from 
which  this  is  obtained  is  not  positively  known.  By  some  it  is 
believed  to  be  derived  from  the  granulations  of  the  discus  proligerus 
which  surround  it  as  it  escapes  from  the  Graafian  follicle,  and  sub- 
sequently from  the  layer  of  albuminous  matter  which  surrounds  the 
ovum  before  it  reaches  the  uterus;  while  others  think  it  probable 
that  it  may  come  from  a  special  liquid  secreted  by  the  interior  of 
the  Fallopian  tube  as  the  ovum  passes  along  it.  As  soon  as  the 
ovum  has  reached  the  uterus,  there  is  every  reason  to  believe  that 
the  umbilical  vesicle  is  the  chief  source  of  nourishment  to  the  embryo, 
through  the  channel  of  the  omphalo-mesenteric  vessels,  which  convey 
matters  absorbed  from  the  interior  of  the  vesicle  to  the  intestinal 
canal  of  the  foetus.  At  this  time  the  exterior  of  the  ovum  is  covered 
by  the  numerous  fine  villosities  of  the  primitive  chorion,  which  are 
imbedded  in  the  mucous  membrane  of  the  uterus,  and  it  is  thought 
that  they  may  absorb  materials  from  the  maternal  system,  which  may 
be  either  directly  absorbed  by  the  embryo,  or  which  may  serve  the 
purpose  of  replacing  the  nutritive  matter  which  has  been  removed 
from  the  umbilical  vesicle  by  the  omphalo-mesenteric  vessels.  This 
point  it  is,  of  course,  impossible  to  decide.  Joulin,  however,  thinks 
that  these  villi  probably  have  no  direct  influence  on  the  nourishment 
of  the  foetus,  which  is  at  this  time  solely  effected  by  the  umbilical 
vesicle,  but  that  they  absorb  fluid  from  the  maternal  system,  which 
passes  through  the  amnion  and  forms  the  liquor  amnii.  As  soon  as 
the  allantois  is  developed,  vascular  communication  between  the  foetus 
arid  the  maternal  structures  is  established,  and  the  temporary  func- 
tion of  the  umbilical  vesicle  is  over  ;  that  structure,  therefore,  rapidly 
atrophies  and  disappears,  and  the  nutrition  of  the  foetus  is  now  solely 
carried  on  by  means  of  the  chorion  villi,  lined  as  they  now  are  by 
the  vascular  endo-chorion,  and  chiefly  by  those  which  go  to  form  the 
substance  of  the  placenta. 

This  statement  is  opposed  to  the  views  of  many  physiologists,  who 
believe  that  a  certain  amount  of  nutritive  material  is  conveyed  to 
the  foetus  through  the  channel  of  the  liquor  amnii,  itself  derived 
from  the  maternal  system,  which  is  supposed  either  to  be  absorbed 
through  the  cutaneous  surface  of  the  foetus,  or  carried  to  the  intesti- 
nal canal  by  deglutition.  The  reasons  for  assigning  to  the  liquor 
amnii  a  nutritive  function  are,  however,  so  slight,  that  it  is  difficult 
to  believe  that  it  has  any  appreciable  action  in  this  way.  They  are 
based  on  some  questionable  observations,  such  as  those  of  Weydlich, 
who  kept  a  calf  alive  for  fifteen  days  by  feeding  it  solely  on  liquor 
amnii,  and  the  experiments  of  Burdach,  who  found  the  cutaneous 
lymphatics  engorged  in  a  foetus  removed  from  the  amniotic  cavity, 
while  those  of  the  intestine  were  empty.  The  deglutition  of  the 
liquor  arnnii  for  the  purposes  of  nutrition,  has  been  assumed  from  its 
occasional  detection  in  the  stomach  of  the  foetus,  the  presence  of 
which  may,  however,  be  readily  explained  by  spasmodic  efforts  at 
respiration,  which  the  foetus  undoubtedly  often  makes  before  birth, 
especially  when  the  placental  circulation  is  in  any  way  interfered  with, 


118  PREGNANCY. 

and  during  \vhich  a  certain  quantity  of  fluid  would  necessarily  be 
swallowed.  The  quantity  of  nutritive  material,  moreover,  in  the 
liquor  amnii  is  so  small — not  more  than  6  to  9  parts  of  albumen  in 
1000 — that  it  is  impossible  to  conceive  how  it  could  have  any 
appreciable  influence  in  nutrition,  even  if  its  absorption,  either  by  the 
skin  or  stomach,  were  susceptible  of  proof. 

That  the  nutrition  of  the  foetus  is  effected  through  the  placenta 
is  proved  by  the  common  observation  that  whenever  the  placental 
circulation  is  arrested,  as  by  disease  of  its  structure,  the  foetus  atro- 
phies and  dies.  The  precise  mode,  however,  in  which  nutritive 
materials  are  absorbed  from  the  maternal  blood  is  still  a  matter  of 
doubt,  and  must  remain  so  until  the  mooted  points  as  to  the  minute 
anatomy  of  the  placenta  are  settled.  The  various  theories  enter- 
tained on  this  subject  by  the  upholders  of  the  Hunterian  doctrine  of 
placental  anatomy,  and  by  those  who  deny  the  existence  of  a  sinus 
system,  have  been  already  referred  to  in  the  chapter  on  the  Anatomy 
of  the  Placenta,  to  which  the  reader  is  referred  (pp.  lO-i-6). 

2.  Respiration. — One  of  the  chief  functions  of  the  placenta,  besides 
that  of  nutrition,  is  the  supply  of  oxygenated  blood  to  the  foetus. 
That  this  is  essential  to  the  vitality  of  the  foetus,  and  that  the  pla- 
centa is  the  site  of  oxgyenation,  are  shown  by  the  facts  that  when- 
ever the  placenta  is  separated,  or  the  access  of  foetal  blood  to  it 
arrested  by  compression  of  the  cord,  instinctive  attempts  at  inspira- 
tion are  made,  and  if  aerial  respiration  cannot  be  performed,  the  foetus 
is  expelled  asphyxiated.  Like  the  other  functions  of  the  foetus  during 
intra-uterine  life,  that  of  respiration  has  been  made  the  subject  of 
numerous  more  or  less  ingenious  hypotheses.  Thus  many  have 
believed  that  the  foetus  absorbed  gaseous  material  from  the  liquor 
amnii,  which  served  the  purpose  of  oxygenating  its  blood,  St.  Hilaire 
thinking  that  this  was  effected  by  minute  openings  in  its  skin, 
Beclard  and  others  through  the  bronchi,  to  which  they  believed  the 
liquor  amnii  gained  access.  Independently  of  the  entire  want  of 
evidence  of  the  absorption  of  gaseous  materials  by  these  channels, 
the  theory  is  disproved  by  the  fact  that  the  liquor  amnii  contains  no 
air  which  is  capable  of  respiration.  Serres  attributed  a  similar  func- 
tion to  some  of  the  chorion  villi,  which  he  believed  penetrated  the 
utricular  glands  of  the  decidua  reflexa,  and  absorbed  gas  from  the 
hydroperione,  or  fluid  situated  between  it  and  the  decidua  vera,  and 
in  this  manner  he  thought  the  foetal  blood  was  oxygenated  until  the 
fifth  month  of  intra-uterine  life,  when  the  placenta  was  fully  formed. 
This  hypothesis,  however,  rests  on  no  accurate  foundation,  for  it  is 
certain  that  the  chorion  villi  do  not  penetrate  the  utricular  glands 
in  the  manner  assumed ;  or,  even  if  they  did,  the  mode  in  which  the 
oxygen  thus  absorbed  by  the  chorion  villi  reaches  the  foetus,  which 
is  separated  from  them  by  the  amnion  and  its  contents,  would  still 
remained  unexplained. 

The  mode  in  which  the  oxygenation  of  the  foetal  blood  is  effected 
before  the  formation  of  the  placenta  remains,  therefore,  as  yet  un- 
known. After  the  development  of  that  organ,  however,  it  is  less 
difficult  to  understand,  for  the  foetal  blood  is  everywhere  brought 


ANATOMY    AND    PHYSIOLOGY    OF    THE    F(ETUS. 

into  such  close  contact  with  the  maternal,  in  the  numerous  minute 
ramifications  of  the  umbilical  vessels,  that  the  interchange  of  gases 
can  readily  be  effected.  The  activity  of  respiration  is  doubtless  much 
less  than  in  extra-uterine  life,  for  the  waste  of  tissue  in  the  foetus  is 
necessarily  comparatively  small,  from  the  fact  of  its  being  suspended 
in  a  fluid  medium  of  its  own  temperature,  and  from  the  absence  of 
the  processes  of  digestion  and  of  respiratory  movements.  The  quan- 
tity of  carbonic  acid  formed  would,  therefore,  be  much  less  than  after 
birth,  and  there  would  be  a  correspondingly  small  call  for  oxygena- 
tion  of  venous  circulation. 

3.  Circulation. — The  functions  of  the  lungs  being  in  abeyance,  it 
is  necessary  that  all  the  foetal  blood  should  be  carried  to  the  placenta 
to  receive  oxygen  and  nutritive  materials.  To  understand  the  mode 
in  which  this  is  effected,  we  must  bear  in  mind  certain  peculiarities 
in  the  circulatory  system  which  disappear  after  birth. 

1.  The  two  sides  of  the  foetal  heart  are  not  separate,  as  in  the 
adult.     The  right  ventricle  in  the  adult  sends  also  the  venous  blood 
to  the  lungs,  through  the  pulmonary  arteries,  to  be  aerated  by  con- 
tact with  the  atmosphere.     In  the  foetus,  however,  only  sufficient 
blood  is  passed  through  the  pulmonary  arteries  to  insure  their  being 
pervious  and  ready  to  carry  blood  to  the  lungs  immediately  after 
birth. 

An  aperture  of  communication,  the  foramen  ovale,  exists  between 
the  two  auricles,  which  is  arranged  so  as  to  permit  the  blood  reach- 
ing the  right  auricle  to  pass  freely  into  the  left, 
but  not  vice  versa.   By  this  means  a  large  portion  FIG.  66. 

of  the  blood  reaching  the  heart  through  the  venae 
cavae,  instead  of  passing,  as  in  the  adult,  into  the 
right  ventricle,  is  directed  into  the  left  auricle. 

2.  Even  with  this  arrangement,  however,  a 
larger  portion  of  blood  would  pass  into  the  pul- 
monary arteries  than  is  required  for  transmission 
to  the  lungs,  and  a  further  provision  is  made  to 
prevent  its  going  to  them  by  means  of  a  foetal 

vessel,  the  ductus  arteriosus  (Fig.  66),  which  arises      Diagram  of  Foetai  Heart, 
from  the  point  of  bifurcation  of  the  pulmonary  (After  Daiton.) 

arteries,  and  opens  into  the  arch  of  the  aorta,    r*  ^orta- 

*      n    i  ..  i  2.  Pulmonary  artery. 

In  consequence  of  this  arrangement  only  a  very     3)  3.  puim0uary  branches, 
small  portion  of  the  blood  reaches  the  lungs  at    4.  Ductus  arteriosus. 
all. 

3.  The  foetal  hypogastric  arteries  are  continued  into  two  large 
arterial  trunks,  which,  passing  into  the  cord,  form   the  umbilical 
arteries,  and  carry  the  impure  foetal  blood  into  the  placenta. 

4.  The  purified  blood  is  collected  into  the  single  umbilical  vein, 
through  which  it  is  carried  to  the  under  surface  of  the  liver,  from 
which  point  it  is  conducted,  by  means  of  another  special  foetal  vessel, 
the  ductus  venosus,  into  the   ascending  vena  cava,  and  the  right 
auricle. 

Course  of  the  Foetal  Circulation. — In  order  to  understand  the  course 
of  the  foetal  blood,  it  may  be  most  conveniently  traced  from  the  point 


120  PREGNANCY. 

where  it  readies  the  under  surface  of  the  liver  through  the  umbilical 
vein.  Part  of  it  is  distributed  to  the  liver  itself,  but  the  greater 
quantity  is  carried  directly  into  the  vena  cava,  through  the  ductus 
venosus.  The  vena  cava  also  receives  the  blood  from  the  foetal  veins 
of  the  lower  extremities,  and  that  portion  of  the  blood  of  the  um- 
bilical vein  which  has  passed  through  the  liver.  This  mixed  blood 
is  carried  up  to  the  right  auricle,  from  which  by  far  the  greater  part 
of  it  is  immediately  directed  into  the  left  auricle,  through  the  fora- 
men ovale.  From  thence  it  passes  into  the  left  ventricle,  which  sends 
the  greater  part  of  it  into  the  head  and  upper  extremities  through 
the  aorta,  a  comparatively  small  quantity  being  transmitted  to  the 
inferior  extremities.  The  blood  which  is  thus  sent  to  the  upper  part 
of  the  body  is  collected  into  the  vena  cava  superior,  by  which  it  is 
thrown  into  the  right  auricle.  Here  the  mass  of  it  is  probably  di- 
rected into  the  right  ventricle,  which  expels  it  into  the  pulmonary 
arteries,  and  from  thence  through  the  ductus  arteriosus  into  the 
descending  aorta.  By  this  arrangement  it  will  be  seen  that  the  de- 
scending aorta  conveys  to  the  lower  part  of  the  body  the  compara- 
tively impure  blood  which  has  already  circulated  through  the  head, 
neck,  and  upper  extremities.  From  the  descending  aorta  a  small 
quantity  of  blood  is  conveyed  to  the  lower  extremities,  the  greater 
part  of  it  being  carried  for  purification  to  the  placenta  through  the 
umbilical  arteries. 

Establishment  of  Independent  Circulation. — As  soon  as  the  child  is 
born  it  generally  cries  loudly,  and  inflates  its  lungs,  and,  in  conse- 
quence, the  pulmonary  arteries  are  dilated,  and  the  greater  portion 
of  the  blood  of  the  right  ventricle  is  at  once  sent  to  the  lungs,  from 
whence,  after  being  arterialized,  it  is  returned  to  the  left  auricle, 
through  the  pulmonary  veins.  The  left  auricle,  therefore,  receives 
more  blood  than  before,  the  right  less,  and  the  placental  circulation 
being  arrested,  no  more  passes  through  the  umbilical  vein.  In  con- 
sequence of  this,  the  pressure  of  the  blood  in  the  two  auricles  is 
equalized,  the  mass  of  the  blood  in  the  right  auricle  no  longer  passes 
into  the  left  (the  valve  of  the  foramen  ovale  being  closed  by  the 
equal  pressure  on  both  sides),  but  directly  into  the  right  ventricle, 
and  from  thence  into  the  pulmonary  arteries,  and  the  ductus  arte- 
riosus soon  collapses  and  becomes  impervious.  The  mass  of  blood  in 
the  descending  aorta  no  longer  finds  its  way  into  the  hypogastric 
arteries,  but  passes  into  the  lower  extremities,  and  the  a'dult  circula- 
tion is  established. 

Changes  after  Birth. — The  changes  which  take  place  in  the  tempo- 
rary vascular  arrangements  of  the  foetus,  prior  to  their  complete  dis- 
appearance, are  of  some  practical  interest.  The  ductus  arteriosus, 
as  has  been  said,  collapses,  chiefly  because  the  mass  of  blood  is  drawn 
to  the  lungs,  and  partly,  perhaps,  by  its  own  inherent  contractility.  Its 
walls  are  found  to  be  thickened,  and  its  canal  closes,  first  in  the  centre, 
and  subsequently  at  its  extremities,  its  aortic  end  remaining  longer  per- 
vious on  account  of  the  greater  pressure  of  blood  from  the  left  side  of 
the  heart  (Fig.  67).  Practical  closure  occurs  within  a  few  days  after 


ANATOMY    AND    PHYSIOLOGY    OF    THE    FCETUS. 


121 


Diagram  of  Heart  of  Infant. 
(After  Daltou.) 

1.  Aorta.  2.  Pulmonary  Artery. 
3,  3.  Pulmonary  branches.  4.  Duc- 
tus  arteriosus  becoming  obliterated. 


birth,  although  Flourens  states  that  it  is  FIG.  67. 

not  completely  obliterated  until  eighteen 
months  or  two  years  have  elapsed.1  Ac- 
cording to  Schroeder,  its  walls  unite  with- 
out the  formation  of  any  thrombus.  The 
foramen  ovale  is  soon  closed  by  its  valve, 
which  contracts  adhesion  with  the  edges 
of  the  aperture,  so  as  effectually  to  occlude 
it.  Sometimes  however,  a  small  canal  of 
communication  between  the  two  auricles 
may  remain  pervious  for  many  months,  or 
even  a  year  and  more,  without,  however, 
any  admixture  of  blood  occurring.  A 
permanently  patulous  condition  of  this 
aperture,  however,  sometimes  exists, 
giving  rise  to  the  disease  known  as 
cyanosis. 

The  umbilical  arteries  and  veins,  and  the  ductus  venosus  soon  also 
become  impermeable,  in  consequence  of  concentric  hypertrophy  of 
their  tissues  and  collapse  of  their  avails.  The  closure  of  the  former 
is  aided  by  the  formation  of  coagula  in  their  interior.  According  to 
Eobin,  a  longer  time  than  is  usually  supposed  elapses  before  they 
become  completely  closed,  the  vein  remaining  pervious  until  the 
twentieth  or  thirtieth  day  after  delivery,  the  arteries  for  a  month  or 
six  weeks.  Pie  has  also  described2  a  remarkable  contraction  of  the 
umbilical  vessels  within  their  sheaths,  at  the  point  where  they  leave 
the  abdominal  walls,  which  takes  place  within  three  or  four  days 
after  birth,  and  seems  to  prevent  hemorrhage  taking  place  when  the 
cord  is  detached. 

Function  of  the  Liver. — The  liver,  from  its  proportionately  large 
size,  apparently  plays  an  important  part  in  the  foetal  economy.  It 
is  not  until  about  the  fifth  month  of  utero-gestation  that  it  assumes 
its  characteristic  structure,  and  forms  -bile,  previous  to  that  time  its 
texture  being  soft  and  undeveloped.  According  to  Claude  Bernard, 
after  this  period  one  of  its  most  important  offices  is  the  formation  of 
sugar,  which  is  found  in  much  larger  amount  in  the  foetus  than  after 
birth.  Sugar  is,  however,  found  in  the  foetal  structures  long  before 
the  development  of  the  liver,  especially  in  the  mucous  and  cutaneous 
tissues,  and  it  seems  probable  that  these,  as  well  as  the  placenta  itself, 
then  fulfil  the  glycogenic  function,  afterwards  chiefly  performed  by 
the  liver.  The  bile  is  secreted  after  the  fifth  month  of  pregnancy, 
and  passes  into  the  intestinal  canal,  and  is  subsequently  collected  in 
the  gall-bladder.  By  some  physiologists  it  has  been  supposed  that 
the  liver,  during  intra-uterine  life,  was  the  chief  seat  of  depuration 
of  the  carbonic  acid  contained  in  the  venous  blood  of  the  foetus.  It 
is,  however,  more  generally  believed  that  this  is  accomplished  solely 
in  the  placenta.  The  bile,  mixed  with  the  mucous  secretion  of  the 


Acad.  des  Sciences,  1854. 
9 


2  Acad.  des  Sciences,  I860.. 


122  PREGNANCY. 

intestinal  tract,  forms  the  meconium  which  is  contained  in  the  intes- 
tines of  the  foetus,  and  which  collects  in  them  during  the  whole  period 
of  intra-uterine  life.  It  is  a  thick,  tenacious,  greenish  substance, 
which  is  voided  soon  after  birth  in  considerable  quantity. 

The  Urine. — Urine  is  certainly  formed  during  intra-uterine  life, 
as  is  proved  by  the  fact  familiar  to  all  accoucheurs,  that  the  bladder 
is  constantly  emptied  instantly  after  birth.  It  has  generally  been 
supposed  that  the  foetus  voided  its  urine  into  the  cavity  of  the  am- 
nion,  and  the  existence  of  traces  of  urea  in  the  liquor  amuii,  as  well 
as  some  cases  of  imperforate  urethra,  in  which  the  bladder  was  found 
to  be  enormously  distended,  and  some  congenital  hydronephrosis 
associated  with  impervious  ureters,  have  been  supposed  to  corrobo- 
rate this  assumption.  The  question  has  been  very  fully  studied  by 
Joulin,  who  has  collected  together  a  large  number  of  instances  in 
which  there  was  imperforate  urethra  without  any  undue  distension 
of  the  bladder.  He  holds  also  that  the  amount  of  urea  found  in  the 
liquor  amnii  is  far  too  minute  to  justify  the  conclusion  that  the  urine 
of  the  foetus  was  habitually  poured  into  it,  although  a  small  quantity 
may,  he  thinks,  escape  into  it  from  time  to  time ;  and  he,  therefore, 
believes  that  the  urine  of  the  foetus  is  only  secreted  regularly  and 
abundantly  after  birth,  and  that  during  intra-uterine  life  its  retention 
is  not  likely  to  give  rise  to  any  functional  disturbance.1 

function  of  the  Nervous  System.  —  There  is  no  doubt  that  the 
nervous  system  acts  to  a  considerable  extent  during  intra-uterine 
life,  and  some  authors  have  even  supposed  that  the  foetus  was  en- 
dowed with  the  power  of  making  instinctive  or  voluntary  movements 
for  the  purpose  of  adapting  itself  to  the  form  of  the  uterine  cavity. 
There  can  be  no  question,  however,  that  the  movements  the  foatus 
performs  are  purely  reflex  and  automatic.  That  it  responds  to  a 
stimulus  applied  to  the  cutaneous  nerves  is  proved  by  the  experi- 
ments of  Tyler  Smith,  who  laid  bare  the  amnion  in  pregnant  rabbits, 
and  found  that  the  foetus  moved  its  limbs  when  these  were  irritated 
through  it.  Pressure  on  the  mother's  abdomen,  cold  applications, 
and  similar  stimuli,  will  also  produce  energetic  foetal  movements. 
The  gray  matter  of  the  brain  in  the  new-born  child  is,  however,  quite 
rudimentary  in  its  structure,  and  there  is  no  evidence  of  intelligent 
action  of  the  nervous  system  until  some  time  after  birth,  and  d  fortiori 
during  pregnancy. 

1  Acad.  des  Sciences,  p.  301. 


PREGNANCY.  123 


CHAPTER  III. 

PREGNANCY. 

As  soon  as  conception  has  taken  place  a  series  of  remarkable 
changes  commence  in  the  uterus,  which  progress  until  the  termina- 
tion of  pregnancy,  and  are  well  worthy  of  careful  study.  They  produce 
those  marvellous  modifications  which  effect  the  transformation  of  the 
small  undeveloped  uterus  of  the  non-pregnant  state  into  the  large 
and  fully-developed  uterus  of  pregnancy,  and  have  no  parallel  in  the 
whole  animal  economy. 

A  knowledge  of  them  is  essential  for  the  proper  comprehension 
of  the  phenomena  of  labor,  and  for  the  diagnosis  of  pregnancy  which 
the  practitioner  is  so  frequently  called  upon  to  make.  Excluding 
the  varieties  of  abnormal  pregnancy,  which  will  be  noticed  in  an- 
other place,  we  shall  here  limit  ourselves  to  a  consideration  of  the 
modifications  of  the  maternal  organism  which  -result  from  simple 
and  natural  gestation. 

Changes  in  the  Uterus. — The  •  unimpregnated  uterus  measures  2J 
inches  in  length,  and  weighs  about  1  oz.,  while  at  the  full  term  of 
pregnancy  it  has  so  immensely  grown  as  to  weigh  24  ozs.,  and  meas- 
ure 12  inches.  This  growth  commences  as  soon  as  the  ovum  reaches 
the  uterus,  and  continues  uninterruptedly  until  delivery.  In  the 
early  months  the  uterus  is  contained  entirely  in  the  cavity  of  the 
pelvis,  and  the  increase  of  size  is  only  apparent  on  vaginal  examina- 
tion, and  that  with  difficulty.  After  the  third  month  the  enlarge- 
ment is  chiefly  in  the  lateral  direction,  so  that  the  whole  body  of  the 
uterus  assumes  more  of  a  spherical  shape  than  in  the  non-pregnant 
state.  If  an  opportunity  of  examining  the  gravid,  uterus  post-mor- 
tem should  occur  at  this  time,  it  will  be  found  to  have  the  form  of  a 
sphere  flattened  somewhat  posteriorly,  and  bulging  anteriorly. 

After  the  ascent  of  the  organ  into  the  abdomen,  it  develops  more 
in  the  vertical  direction,  so  that  at  term  it  has  the  form  of  an  ovoid, 
with  its  large  extremity  above  and  its  narrow  end  at  the  cervix  uteri, 
and  its  longitudinal  axis  corresponds  to  the  long  diameter  of  the 
mother's  abdomen,  provided  the  presentation  be  either  of  the  head 
or  breach.  The  anterior  surface  is  now  even  more  distinctly  pro- 
jecting than  before — a  fact  which  is  explained  by  the  proximity  of 
the  posterior  surface  to  the  rigid  spinal  column  behind,  while  the 
anterior  is  in  relation  with  the  lax  abdominal  parietes,  which  yield 
readily  to  pressure,  and  so  allow  of  the  more  marked  prominence  of 
the  anterior  uterine  wall. 

Change  in  Situation. — Before  the  gravid  uterus  has  risen  out  of  the 
pelvis  no  appreciable  increase  in  the  size  of  the  abdomen  is  percep- 
tible. On  the  contrary,  it  is  an  old  observation  that  at  this  early 


124 


PREGNANCY. 


FlG.  68. 


stage  of  pregnancy  the  abdomen  is  flatter  than  usual,  on  account  of 
the  partial  descent  of  the  uterus  in  the  pelvic  cavity  as  a  result  of  its 
increased  weight.  As  the  growth  of  the  organ  advances  it  soon  be- 
comes too  large  to  be  contained  any  longer  within  the  pelvis,  and 
about  the  middle  of  the  third  or  the  beginning  of  the  fourth  month 
the  fundus  rises  above  the  pelvic  brirn — not  suddenly,  as  is  often 
erroneously  thought,  but  slowly  and  gradually — when  it  may  be  felt 
as  a  smooth  rounded  swelling. 

Size  at  various  Periods  of  Preynancy. — It  is  about  this  time  that 
the  movements  of  the  foetus  first  become  appreciable  to  the  mother, 
when  "  qiiickeniny"  is  said  to  have  taken  place.  Towards  the  end  of 
the  fourth  month  the  uterus  reaches  to  about  three  fingers'  breadth 
above  the  symphysis  pubis.  About  the  fifth  month  it  occupies  the 
hypogastric  region,  to  which  it  imparts  a  marked  projection,  and  the 
alteration  in  the  figure  is  now  distinctly  perceptible  to  visual  exami- 
nation. About  the  sixth  month  it  is  on  a  level  with,  or  a  little 
above,  the  umbilicus.  About  the  seventh  month  it  is  about  two 
inches  above  the  umbilicus,  which  is  now  projecting  and  prominent, 
instead  of  depressed,  as  in  the  non-pregnant  state.  During  the  eighth 
and  ninth  months  it  continues  to  increase  until  the  summit  of  the 
fuudus  is  immediately  below  the  ensiform  cartilage  (Fig.  68).  A 

knowledge  of  the  size  of  the  uterine 
tumor  at  various  periods  of  preg- 
nancy, as  thus  indicated,  is  of  consid- 
erable practical  importance,  as  form- 
ing the  only  guide  by  which  we  can  es- 
timate the  probable  period  of  delivery 
in  certain  cases  in  which  the  usual 
data  for  calculation  are  absent,  as,  for 
example,  when  the  patient  has  con- 
ceived during  lactation. 

The  Uterus  Sinks  before  Delivery. 
— For  about  a  week  or  more  before 
labor  the  uterus  generally  sinks  some- 
what into  the  pelvic  cavity,  in  con- 
sequence of  the  relaxation  of  the  soft 
parts  which  precedes  delivery,  and 
the  patient  no\v  feels  herself  smaller 
and  lighter  than  before.  This  change 
is  familiar  to  all  child-bearing  women, 
to  whom  it  is  known  as  "the  lighten- 
ing before  labor." 

The  Direction  of  the  Uterus. — "While 
the  uterus  remains  in  the  pelvis  its 

longitudinal  axis  varies  in  direction,  much  in  the  same  way  as  that 
of  the  non-pregnant  uterus,  sometimes  being  more  or  less  vertical, 
at  others  in  a  state  of  anteversion  or  partial  retroversion.  These 
variations  are  probably  dependent  on  the  distension  or  emptiness  of 
the  bladder,  as  its  state  must  necessarily  affect  the  position  of  the 
movable  organ  poised  behind  it.  After  the  uterus  has  risen  into  the 


Size  of  Uterus  at  various  Periods  of 
Pregnancy. 


PREGNANCY.  125 

abdomen  its  tendency  is  to  project  forwards  against  the  abdominal 
wall,  which  forms  its  chief  support  in  front.  In  the  erect  position 
the  long  axis  of  the  uterine  tumor  corresponds  with  the  axis  of  the 
pelvic  brim,  forming  an  angle  of  about  30°  with  the  horizon.  In  the 
semi-recumbent  position,  on  the  other  hand,  as  Duncan1  has  pointed 
out,  its  direction  becomes  much  more  nearly  vertical.  In  women  who 
have  borne  many  children,  the  abdominal  parietes  no  longer  afford 
an  efficient  support,  and  the  uterus  is  displaced  anteriorly,  the  fundus 
in  extreme  cases  even  hanging  downwards. 

Lateral  Obliquity  of  the  Uterus.- — In  addition  to  this  anterior  ob- 
liquity, on  account  of  the  projection  of  the  spinal  column,  the  uterus 
is  very  generally  also  displaced  laterally,  and  sometimes  to  a  very 
marked  degree,  so  that  it  may  be  felt  entirely  in  one  flank,  instead 
of  in  the  centre  of  the  abdomen.  In  a  large  proportion  of  cases  this 
lateral  deviation  is  to  the  right  side,  and  many  hypotheses  have 
been  brought  forward  to  explain  this  fact,  none  of  them  being  satis- 
factory. Thus,  it  has  been  supposed  to  depend  on  the  greater  fre- 
quency with  which  women  lie  on  their  right  side  during  sleep,  on  the 
greater  use  of  the  right  leg  during  walking,  on  the  supposed  com- 
parative shortness  of  the  right  round  ligament,  which  drags  the 
tumor  to  that  side,  or  on  the  frequent  distension  of  the  rectum  on  the 
left  side,  which  prevents  the  uterus  being  displaced  in  that  direction. 
Of  these  the  last  is  the  cause  which  seems  most  constantly  in  opera- 
tion, and  most  likely  to  produce  the  effect. 

Changes  in  the  Direction  of  the  Cervix. — The  cervix  must  obviously 
adapt  itself  to  the  situation  of  the  body  of  the  uterus.  We  find, 
therefore,  that  in  the  early  months,  when  the  uterus  lies  low  in  the 
pelvis,  it  is  more  readily  within  reach.  After  the  ascent  of  the 
uterus,  it  is  drawn  up,  and  frequently  so  much  so  as  to  be  reached 
with  difficulty.  When  the  uterus  is  much  anteverted,  as  is  so  often 
the  case,  the  os  is  displaced  backwards,  so  that  it  cannot  be  felt  at 
all  by  the  examining  ringer. 

Relation  of  the  Uterus  to  the  Surrounding  Parts. — Towards  the  end 
of  pregnancy  the  greater  part  of  the  anterior  surface  of  the  uterus  is 
in  contact  with  the  abdominal  wall,  its  lower  portion  resting  on  the 
posterior  surface  of  the  symphysis  pubis.  The  posterior  surface  rests 
on  the  spinal  column,  while  the  small  intestines  are  pushed  to  either 
side,  the  large  intestines  surrounding  the  uterus  like  an  arch. 

Changes  in  the  Uterine  Parietes. — The  great  distension  of  the  uterus 
during  pregnancy  was  formerly  supposed  to  be  mainly  due  to  the 
mechanical  pressure  of  the  enlarging  ovum  within  it.  If  this  were 
so,  then  the  uterine  walls  would  be  necessarily  much  thinner  than  in 
the  non-pregnant  state.  This  is  well  known  not  to  be  the  case,  and 
the  immense  increase  in  the  size  of  the  uterine  cavity  is  to  be  ex- 
plained by  the  hypertrophy  of  its  walls.  At  the  full  period  of  preg- 
nancy the  thickness  of  the  uterine  parietes  is  generally  about  the 
same  as  that  of  the  non-pregnant  uterus,  rather  more  at  the  placental 
site,  and  less  in  the  neighborhood  of  the  cervix.  Their  thickness, 

1  Researches  in  Obstetrics,  p.  10. 


126 


PREGNANCY. 


however,  varies  in  different  cases,  and  in  some  women  they  are  so 
thin  as  to  admit  of  the  foatal  limbs  being  very  readily  made  out  by 
palpation.  Their  density  is,  however,  always  much  diminished,  and, 
instead  of  being  hard  and  inelastic,  they  become  soft  and  yielding  to 
pressure.  This  change  coincides  with  the  commencement  of  preg- 
nancy, of  which  it  forms,  as  recognizable  in  the  cervix,  one  of  the 
earliest  diagnostic  marks.  At  a  more  advanced  period  it  is  of  value 
as  admitting  a  certain  amount  of  yielding  of  the  uterine  walls  to 
the  movements  of  the  foetus,  thus  lessening  the  chance  of  their  being 
injured. 

Changes  in  the  Cervix  during  Pregnancy. — Very  erroneous  views 
have  long  been  taught,  in  most  of  our  standard  works  on  midwifery, 
as  to  the  changes  which  occur  in  the  cervix  uteri  during  pregnancy. 
It  is  generally  stated  that,  as  pregnancy  advances,  the  cervical  cavity 
is  greatly  diminished  in  length,  in  consequence  of  its  being  gradually 
drawn  up  so  as  to  form  part  of  the  general  cavity  of  the  uterus,  so 
that  in  the  latter  months  it  no  longer  exists.  In  almost  all  midwifery 
works  accurate  diagrams  are  given  of  this  progressive  shortening  of 
the  cervix  (Figs.  69  to  72).  The  cervix  is  generally  described  as 

FIGS.  69,  70,  71,  72. 


Supposed  Shortening  of  the  Cervix  at  the  Third,  Sixth,  Eighth,  and  Ninth  Months  of  Pregnancy,  as 

Figured  in  Obstetric  Works. 

having  lost  one-half  of  its  length  at  the  sixth  month,  two-thirds  at 
the  seventh,  and  to  be  entirely  obliterated  in  the  eighth  and  ninth. 
The  correctness  of  these  views  was  first  called  in  question  in  recent 
times  by  Stoltz,  in  1826,  but  Dr.  Duncan,1  in  an  elaborate  historical 
paper  on  the  subject,  has  shown  that  Stoltz  was  anticipated  by  Weit- 
brech  in  1750,  and,  to  a  less  degree,  by  Roederer  and  other  writers. 
This  opinion  is  now  pretty  generally  admitted  to  be  correct,  and  is 
upheld  by  Cazeaux,  Arthur  Farre,  Duncan,  and  most  modern  obstet- 
ricians. Indeed,  various  post-mortem  examinations  in  advanced 
pregnancy  have  shown  that  the  cavity  of  the  cervix  remains  in 

1  Researches  in  Obstetrics. 


PREGNANCY, 


127 


reality  of  its  normal  length  of  one  inch,  and  it  can  often  be  measured 
during  life  by  the  examining  finger,  on  account  of  its  patulous  state 
(Fig.  73).  Daring  the  fortnight  immediately  preceding  delivery, 
however,  a  real  shortening  or  obliteration  of  the  cervical  cavity  takes 


Cervix  from  a  Woman  Dying  in  the  Eighth  Month  of  Pregnancy.     (After  Duncan.) 

place ;  but  this,  as  Duncan  has  pointed  out,  seems  to  be  due  to  the 
incipient  uterine  contractions,,  which  prepare  the  cervix  for  labor. 

Apparent  Shortening. — There  is,  no  doubt,  an  apparent  shortening 
of  the  cervix  always  to  be  detected  during  pregnancy,  but  this  is  a 
fallacious  and  deceptive  feeling,  due  to  the  softness  of  the  tissue  of 
the  cervix,  which  is  exceedingly  characteristic  of  pregnancy,  and 
which  to  an  experienced  finger  affords  one  of  its  best  diagnostic 
marks. 

Softening  of  the  Cervix. — In  the  non-pregnant  state  the  tissue  of 
the  cervix  is  hard,  firm,  and  inelastic.  When  conception  occurs, 
softening  begins  at  the  external  os,  and  proceeds  gradually  and  slowly 
upwards  until  it  involves  the  whole  of  the  cervix.  By  the  end  of 
the  fourth  month  both  lips  of  the  os  are  thick,  softened,  and  velvety 
to  the  touch,  giving  a  sensation,  likened  by  Cazeaux  to  that  produced 
by  pressing  on  a  table  through  a  thick,  soft  cover.  By  the  sixth 
month  at  least  one-half  of  the  cervix  is  thus  altered,  and  by  the 
eighth  the  whole  of  it,  and  so  much  so  that  at  this  time  those  unac- 
customed to  vaginal  examination  experience  some  difficulty  in  dis- 
tinguishing it  from  the  vaginal  walls.  It  is  this  softening,  then, 
which  gives  rise  to  the  apparent  shortening  of  the  cervix  so  gene- 
rally described,  and  it  is  an  invariable  concomitant  of  pregnancy 


128  PREGNANCY. 

except  in  some  rare  cases  in  which  there  has  been  antecedent  morbid 
induration  and  hypertrophic  elongation  of  the  cervix.  If,  therefore, 
on  examining  a  woman  supposed  to  be  advanced  in  pregnancy,  we 
find  the  cervix  to  be  hard  and  projecting  into  the  vaginal  canal,  we 
may  safely  conclude  that  pregnancy  does  not  exist.  The  existence 
of  softening,  however,  it  must  be  remembered,  will  not  of  itself 
justify  an  opposite  conclusion,  as  it  may  be  produced,  to  a  very  con- 
siderable extent,  by  various  pathological  conditions  of  the  uterus. 

The  Os  Uteri  is  generally  Patulous. — At  the  same  time  that  the 
tissue  of  the  cervix  is  softened,  its  cavity  is  widened,  and  the  external 
os  becomes  patulous.  This  change  varies  considerably  in  primiparae 
and  multipart.  In  the  former  the  external  os  often  remains  closed 
until  the  end  of  pregnancy ;  but  even  in  them  it  generally  becomes 
more  or  less  patulous  after  the  seventh  month,  and  admits  the  tip  of 
the  examining  finger.  In  women  who  have  borne  children  this 
change  is  much  more  marked.  The  lips  of  the  external  os  are  in 
them  generally  fissured  and  irregular,  from  slight  lacerations  of  its 
tissue  in  former  labors.  It  is  also  sufficiently  open  to  admit  the  tip 
of  the  finger,  so  that  in  the. latter  months  of  pregnancy  it  is  often 
quite  possible  to  touch  the  membranes,  and  through  them  to  feel  the 
presenting  part  of  the  child. 

Changes  in  the  Texture  of  the  Uterine  Tissues. — The  remarkable 
increase  in  size  of  the  uterus  during  pregnancy  is,  as  we  have  seen, 
chiefly  to  be  explained  by  the  growth  of  its  structures,  all  of  which 
are  modified  during  gestation.  The  peritoneal  covering  is  consider- 
ably increased,  so  as  still  to  form  a  complete  covering  to  the  uterus 
when  at  its  largest  size.  William  Hunter  supposed  that  its  extension 
was  affected  rather  by  the  unfolding  of  the  layers  of  the  broad  liga- 
ment, than  by  growth.  That  the  layers  of  the  broad  ligament  do 
unfold  during  gestation,  especially  in  the  early  months,  is  probable ; 
but  this  is  not  sufficient  to.  account  for  the  complete  investment  of 
the  uterus,  and  it  is  certain  that  the  peritoneum  grows  par i  passu 
with  the  enlargement  of  the  uterus.  In  addition  there  is  a  new  for- 
mation of  fibrous  tissue  between  the  peritoneal  and  the  muscular 
coats,  which  affords  strength,  and  diminishes  the  risk  of  laceration 
during  labor. 

Muscular  Coat. — The  hypertrophy  of  the  muscular  tissue  of  the 
uterus  is,  however,  the  most  remarkable  of  the  changes  produced  by 
pregnancy.  Not  only  do  the  previously-existing  rudimentary  fibre- 
cells  become  enormously  increased  in  size — so  as  to  measure,  accord- 
ing to  Kdlliker,  from  seven  to  eleven  times  their  former  length,  and 
from  two  to  five  times  their  former  breadth — but  new  unstriped 
fibres  are  largely  developed,  especially  in  the  inner  layers.  These 
new  cells  are  chiefly  found  in  the  first  months  of  pregnancy,  and 
their  growth  seems  to  be  completed  by  the  sixth  month.  The  con-, 
nective  tissue  between  the  muscular  layers  is  also  largely  increased 
in  amount.  The  weight  of  the  muscular  tissue  of  the  gravid  uterus 
is,  therefore,  much  increased,  and  it  has  been  estimated  by  Heschl 
that  it  weighs  at  term  from  1  to  1.5  Ibs.,  that  is,  about  sixteen  times 
more  than  in  the  unimpregnated  state.  This  great  development  of 


PREGNANCY.  129 

the  muscular  tissue  admits  of  its  dissection  in  a  way  which  is  quite 
impossible  in  the  uni impregnated  state,  and  the  recent  researches  of 
Helie  (p.  53)  enable  us  to  understand  much  1  tetter  than  before  how 
the  muscles  forming  the  walls  of  the  gravid  uterus  act  during  the 
expulsion  of  the  child. 

The  changes  in  the  mucous  coat  of  the  uterus,  which  result  in  the 
formation  of  the  decidua,  have  already  been  discussed  at  length  else- 
where (p.  89). 

Circulatory  Apparatus.- — The  circulatory  apparatus  of  the  uterus 
during  pregnancy  has  been  described  when  the  anatomy  of  the 
placenta  was  under  consideration  (p.  103). 

Lymphatics. — The  lymphatics  are  much  increased  in  size ;  and  re- 
cent theories  on  the  production  of  certain  puerperal  diseases  attribute 
to  them  a  more  important  action  than  has  been  commonly  assigned 
to  them. 

Nerves. — The  question  of  the  growth  of  the  nerves  has  been  hotly 
discussed.  Robert  Lee  took  the  foremost  place  among  those  who 
maintain  that  the  nerves  of  the  uterus  share  the  general  growth  of 
its  other  constituent  parts.  Dr.  Snow  Beck,  however,  believed  that 
they  remain  of  the  same  size  as  in  the  unimpregnated  state,  and  this 
view  is  supported  by  Hirschfeld,  Robin,  and  other  recent  writers. 
Robin  thought  that  there  was  an  apparent  increase  in  the  size  of  the 
nerve-tubes,  which,  however,  is  really  due  to  increase  in  the  neuri- 
lemma.  Kilian  describes  the  nerves  as  increasing  in  length  but  not 
in  thickness;  while  Schroeder  states  that  they  participate  equally 
with  the  lymphatics  in  the  enlargement  the  latter  undergo.  Which- 
ever of  these  views  may  ultimately  be  found  to  be  correct,  it  is  cer- 
tain that  analogy  would  lead  us  to  expect  an  increase  of  nervous,  as 
well  as  of  vascular,  supply. 

General  Modification  in  the  Body  produced  by  Pref/nancy. — It  is  not 
in  the  uterus  alone,  that  pregnancy  is  found  to  produce  modifications 
of  importance.  There  are  few  of  the  more  important  functions  of 
the  body  which  are  not,  to  a  greater  or  less  extent,  affected ;  to  some 
of  these  it  is  necessary  briefly  to  direct  attention,  inasmuch  as,  when 
carried  to  excess,  they  produce  those  disorders  which  often  compli- 
cate gestation,  and  which  prove  so  distressing  and  even  dangerous 
to  the  patients.  Such  of  them  as  are  apparent  and  may  aid^us  in 
diagnosis  are  discussed  in  the  chapter  which  treats  of  the  signs  and 
symptoms  of  pregnancy ;  in  this  place  it  is  only  necessary  to  refer  to 
those  which  do  not  properly  fall  into  that  category. 

Changes  in  the  Blood. — Amongst  those  which  are  most  constant 
and  important  are  the  alterations  in  the  composition  of  the  blood. 
The  opinion  of  the  profession  on  this  subject  has,  of  late  years,  under- 
gone a  remarkable  change.  Formerly  it  was  universally  believed 
that  pregnancy  was,  as  the  rule,  associated  with  a  condition  analagous 
to  plethora,  and  that  this  explained  many  characteristic  phenomena 
of  common  occurrence,  such  as  headache,  palpitation,  singing  in  the 
ears,  shortness  of  breadth,  and  the  like.  As  a  consequence  it  was 
the  habitual  custom,  not  yet  by  any  means  entirely  abandoned,  to 
treat  pregnant  women  on  an  antiphlogistic  system  ;  to  place  them  on 


130  PREGNANCY. 

low  diet,  to  administer  lowering  remedies,  and  very  often  to  practice 
venesection,  sometimes  to  a  surprising  extent.  Thus  it  was  by  no 
means  rare  for  women  to  be  bled  six  or  eight  times  during  the  latter 
months,  even  when  no  definite  symptoms  of  disease  existed;  and 
many  of  the  older  authors  record  cases  where  depletion  was  practised 
every  fortnight,  as  a  matter  of  routine,  and,  when  the  symptoms 
were  well  marked,  even  from  fifty  to  ninety  times  in  the  course  of  a 
single  pregnancy. 

Composition  of  the  Blood  in  Pregnancy. — Numerous  careful  analyses 
have  conclusively  proved  that  the  composition  of  the  blood  during 
pregnancy  is  very  generally — perhaps  it  would  not  be  too  much  to 
say  always — profoundly  altered.  Thus  it  is  found  to  be  more  watery, 
its  serum  is  deficient  in  albumen,  and  the  amount  of  colored  globules 
is  materially  diminished,  averaging,  according  to  the  analyses  of 
Becquerel  and  Eodier,  111.8  against  127.2  in  the  non-gravid  state. 
At  the  same  time  the  amount  of  fibrine  and  of  extractive  matter  is 
considerably  increased.  The  latter  observation  is  of  peculiar  im- 
portance, as  it  goes  far  to  explain  the  frequency  of  certain  thrombotic 
affections,  observed  in  connection  with  pregnancy  and  delivery  ;  this 
hyperinosis  of  the  blood  is  also  considerably  increased  after  labor  by 
the  quantity  of  effete  material  thrown  into  the  mother's  system  at 
that  time,  to  be  got  rid  of  by  her  emunctories.  The  truth  is,  that 
the  blood  of  the  pregnant  woman  is  generally  in  a  state  much  more 
nearly  approaching  the  condition  of  anaemia  than  of  plethora,  and  it 
is  certain  that  most  of  the  phenomena  attributed  to  plethora  may  be 
explained  equally  well  and  better  on  this  view.  These  changes  are 
much  more  strongly  marked  at  the  latter  end  of  pregnancy  than  at 
its  commencement,  and  it  is  interesting  to  observe  that  it  is  then  that 
the  concomitant  phenomena  alluded  to  are  most  frequently  met  with. 
Cazeaux,  to  whom  we  are  chiefly  indebted  for  insisting  on  the 
practical  bearing  of  these  views,  contends  that  the  pregnant  state  is 
essentially  analogous  to  chlorosis,  and  that  it  should  be  so  treated. 
Objection  has  not  unnaturally  been  taken  to  this  theory,  as  implying 
that  a  healthy  and  normal  function  is  associated  with  a  morbid  state, 
and  it  has  been  suggested  that  this  deteriorated  state  of  the  blood 
may  be  a  wise  provision  of  nature  instituted  for  a  purpose  we  are  not 
as  yet  able  to  understand.  It  may  certainly  be  admitted  that  preg- 
nancy, in  a  perfectly  healthy  state  of  the  system,  should  not  be 
associated  with  phenomena  in  themselves  in  any  degree  morbid.  It 
must  not  be  forgotten,  however,  that  our  patients  are  seldom,  we 
might  safely  say  never,  in  a  state  that  is  physiologically  healthy. 
The  influence  of  civilization,  climate,  occupation,  diet,  and  a  thousand 
other  disturbing  causes  that,  to  a  greater  or  less  degree,  are  always 
to  be  met  with,  must  not  be  left  out  of  consideration.  Making  every 
allowance,  therefore,  for  the  undoubted  fact  that  pregnancy  ouyJii  to 
be  a  perfectly  healthy  condition,  it  must  be  conceded,  I  think,  that 
in  the  vast  majority  of  cases  coming  under  our  notice  it  is  not  entirely 
so ;  and  the  deductions  drawn  by  Cazeaux,  from  the  numerous 
analyses  of  the  blood  of  pregnant  women,  seem  to  point  strongly  to 
the  conclusion  that  the  general  blood-state  is  one  of  poverty  and 


PREGNANCY.  181 

anosmia,  and  that  a  depressing  and  antiphlogistic  treatment  is  dis- 
tinctly contra-indicated. 

Modifications  in  certain  Viscera. — Closely  connected  with  the  al- 
tered condition  of  the  blood  is  the  physiological  hypertrophy  of  the 
heart,  which  is  now  well  known  to  occur  during  pregnancy.  This 
was  first  pointed  out  by  Larcher  in  1828,  and  it  has  been  since  veri- 
fied by  numerous  observers.  It  seems  to  be  constant  and  considera- 
ble, and  to  be  a  purely  physiological  alteration  intended  to  meet  the 
increased  exigencies  of  the  circulation,  which  the  complex  vascular 
arrangements  of  the  gravid  uterus  produce.  The  hypertrophy  is 
limited  to  the  left  ventricle  ;  the  right  ventricle,  as  well  as  both  au- 
ricles, being  unaffected.  Blot  estimates  that  the  whole  weight  of  the 
heart  increases  one-fifth  during  gestation.  The  more  recent  re- 
searches of  Lohlein1  render  it  probable  that  the  hypertrophy  is  less 
than  these  authors  have  supposed.  According  to  Duroziez2  the  heart 
remains  enlarged  during  lactation,  but  diminishes  in  size  immediately 
after  delivery  in  women  who  do  not  suckle,  while  in  women  who 
have  borne  many  children  it  remains  permanently  somewhat  larger 
than  in  nulliparae.  Similar  increase  in  the  size  of  other  organs  has 
been  pointed  out  by  various  writers,  as,  for  example,  in  the  lym- 
phatics, the  spleen,  and  the  liver.  Tarnier  states  that  in  women  who 
have  died  after  delivery,  the  organs  always  show  signs  of  fatty  de- 
generation. According  to  Gassner  the  whole  body  increases  in  weight 
during  the  latter  months  of  pregnancy,  and  this  increase  is  somewhat 
beyond  that  which  can  be  explained  by  the  size  of  the  womb  and  its 
contents. 

Formation  of  Osteophytes. — Irregular  bony  deposits  between  the 
skull  and  the  dura  mater,  in  some  cases  so  largely  developed  as  to 
line  the  whole  cranium,  have  been  so  frequently  detected  in  women 
who  have  died  during  parturition,  that  they  are  believed  by  some  to 
be  a  normal  production  connected  with  pregnancy.  Ducrest  found 
these  osteophytes  in  more  than  one-third  of  the  cases  in  which  he 
performed  post-mortem  examinations  during  the  puerperal  period. 
Rokitansky,  who  corroborated  the  observation,  believed  this  peculiar 
deposit  of  bony  matter  to  be  a  physiological,  and  not  a  pathological 
condition  connected  with  pregnancy  ;  but  whether  it  be  so,  or  how 
it  is  produced,  has  not  yet  been  satisfactorily  determined. 

Changes  in  the  Nervous  System. — More  or  less  marked  changes  con- 
nected with  the  nervous  system  are  generally  observed  in  pregnancy, 
and  sometimes  to  a  very  great  extent.  When  carried  to  excess  they 
produce  some  of  the  most  troublesome  disorders  which  complicate 
gestation,  such  as  alterations  in  the  intellectual  functions,  changes  in 
the  disposition  and  character,  morbid  cravings,  dizziness,  neuralgia, 
syncope,  and  many  others.  They  are  purely  functional  in  their  cha- 
racter, and  disappear  rapidly  after  delivery,  and  may  be  best  de- 
scribed in  connection  with  the  disorders  of  pregnancy. 

Changes  in  the  Respiratory  Organs. — Respiration  is  often  inter- 
fered with,  from  the  mechanical  results  of  the  pressure  of  the  en- 

1  Zeitschrift  fur  Geburtshiilfe,  etc.,  1876.  2  Gaz.  des  H6pit.  1868. 


132  PREGNANCY. 

larged  uterus.  The  longitudinal  dimensions  of  the  thorax  are 
lessened  by  the  upward  displacement  of  the  diaphragm,  and  this 
necessarily  leads  to  some  embarrassment  of  the  respiration,  which 
is,  however,  compensated,  to  a  great  extent,  by  an  increase  in  breadth 
of  the  base  of  the  thoracic  cavity. 

Changes  in  the  Urine. — Certain  changes,  which  are  of  very  con- 
stant occurrence,  in  the  urine  of  pregnant  women  have  attracted 
much  attention,  and  have  been  considered  by  many  writers  to  be 
pathognomonic.  They  consist  in  the  presence  of  a  peculiar  deposit, 
formed  when  the  urine  has  been  allowed  to  stand  for  some  time, 
which  has  received  the  name  of  kiestein.  Its  presence  was  known 
to  the  ancients,  and  it  was  particularly  mentioned  by  Savonarola  in 
the  fifteenth  century,  but  it  has  more  especially  been  studied  within 
the  last  thirty  years  by  Eguisier,  Golding  Bird,  and  others.  If  the 
urine  of  a  pregnant  woman  be  allowed  to  stand  in  a  cylindrical  ves- 
sel, exposed  to  light  and  air,  but  protected  from  dust,  in  a  period, 
varying  from  two  to  seven  days,  a  peculiar  flocculent  sediment,  like 
fine  cotton- wool,  makes  its  appearance  in  the  centre  of  the  fluid,  and 
soon  afterwards  rises  to  the  surface  and  forms  a  pellicle,  which  has 
been  compared  to  the  fat  on  cold  mutton-broth.  In  the  course  of  a 
few  days  the  scum  breaks  up  and  falls  to  the  bottom  of  the  vessel. 
On  microscopic  examination  it  is  found  to  be  composed  of  fat  parti- 
cles, with  crystals  of  ammoniaco-magnesium  phosphates  and  phosphate 
of  lime,  and  a  large  quantity  of  vibriones.  These  appearances  are 
generally  to  be  detected  after  the  second  month  of  pregnancy,  and 
up  to  the  seventh  or  eighth  month,  after  which  they  are  rarely  pro- 
duced. Regnauld  explains  their  absence  during  the  latter  months 
of  gestation  by  the  presence  in  the  urine,  at  that  time,  of  free  lactic 
acid,  which  increases  its  acidity,  and  prevents  the  decomposition  of 
the  urea  into  carbonate  of  ammonia.  He  believes  that  kiestein  is 
produced  by  the  action  of  free  carbonate  of  ammonia  on  the  phos- 
phate of  lime  contained  in  the  urine,  and  that  this  reaction  is  pre- 
vented by  the  excess  of  acid. 

Golding  Bird  believed  kiestein  to  be  analogous  to  casein,  to  the 
presence  of  which  he  referred  it,  and  he  states  that  he  has  found  it 
in  twenty-seven  out  of  thirty  cases.  Braxton  Hicks  so  far  corrobo- 
rates his  view,  and  states  that  the  deposit  of  kiestein  can  be  much 
more  abundantly  produced  if  one  or  two  teaspoonfuls  of  rennet  be 
added  to  the  urine,  since  that  substance  has  the  property  of  coagu- 
lating casein.  Much  less  importance,  however,  is  now  attached  to 
the  presence  of  kiestein  than  formerly,  since  a  precisely  similar  sub- 
stance is  sometimes  found  in  the  urine  of  the  non-pregnant,  especially 
in  ansemic  women,  and  even  in  the  urine  of  men.  Parkes  states  that 
it  is  not  of  uniform  composition,  that  it  is  produced  by  the  decompo- 
sition of  urea,  and  consists  of  the  free  phosphates,  bladder  mucus, 
infusoria,  and  vaginal  discharges.  Neugebauer  and  Vogel  give  a 
similar  account  of  it,  and  hold  that  it  is  of  no  diagnostic  value.  That 
it  is  of  interest,  as  indicating  the  changes  going  on  in  connection  with 
pregnancy,  is  certain ;  but  inasmuch  as  it  is  not  of  invariable  occur- 
rence, and  may  even  exist  quite  independently  of  gestation,  it  is 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  133 

obviously  quite  undeserving  of  the  extreme  importance  that  has  been 
attached  to  it. 

[Although  not  a  reliable  test  of  pregnancy,  it  is  a  remarkable  fact, 
that  in  all  the  cases  of  suspected  impregnation  in  private  practice  in 
Avhich  we  have  employed  it,  we  never  found  a  woman  pregnant  who 
had  not  shown  it  in  her  urine. — -ED.] 


CHAPTER  IV. 

SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

Importance  of  the  Subject. — In  attempting  to  ascertain  the  presence 
or  absence  of  pregnancy,  the  practitioner  has  before  him  a  problem 
which  is  often  beset  with  great  difficulties,  and  on  the  proper  solution 
of  which,  the  moral  character  of  his  patient,  as  well  as  his  own  pro- 
fessional reputation,  may  depend.  The  patient  and  her  friends  can 
hardly  be  expected  to  appreciate  the  fact,  that  it  is  often  far  from 
easy  to  give  a  positive  opinion  on  the  point;  and  it  is  always  advis- 
able to  use  much  caution  in  the  examination,  and  not  to  commit 
ourselves  to  a  positive  opinion,  except  on  the  most  certain  grounds. 
This  is  all  the  more  important,  because  it  is  just  in  those  cases  in 
which  our  opinion  is  most  frequently  asked,  that  the  statements  of 
the  patient  are  of  least  value,  as  she  is  either  anxious  to  conceal  the 
existence  of  pregnancy,  or,  if  desirous  of  an  affirmative  diagnosis, 
unconsciously  colors  her  statements,  so  as  to  bias  the  judgment  of 
the  examiner. 

Constant  attempts  have  been  made  to  classify  the  signs  of  preg- 
nancy ;  thus  some  divide  them  into  the  natural  and  sensible  signs, 
others  into  the  presumptive,  the  probable,  and  the  certain.  The  latter 
classification,  which  is  that  adopted  by  Montgomery  in  his  classical 
work  on  the  "Signs  and  Symptoms  of  Pregnancy,"  is  no  doubt  the 
better  of  the  two,  if  any  be  required.  The  simplest  way  of  studying 
the  subject,  however,  is  the  one,  now  generally  adopted,  of  considering 
the  signs  of  pregnancy  in  the  order  in  which  they  occur,  and  attaching 
to  each  an  estimate  of  its  diagnostic  value. 

Si'jns  of  a  fruitful  Conception. — From  the  earliest  ages  authors 
have  thought,  that  the  occurrence  of  conception  might  be  ascertained 
by  certain  obscure  signs,  such  as  a  peculiar  appearance  of  the  eyes, 
swelling  of  the  neck,  or  by  unusual  sensations  connected  with  a 
fruitful  intercourse.  All  of  these,  it  need  hardly  be  said,  are  far  too 
uncertain  to  be  of  the  slightest  value.  The  last  is  a  symptom  on 
which  many  married  women  profess  themselves  able  to  depend,  and 
one  to  which  Cazeaux  is  inclined  to  attach  some  importance. 


184  PREGNANCY. 

Cessation  of  Menstruation. — The  first  appreciable  indication  of 
pregnancy,  on  which  any  dependence  can  be  placed,  is  the  cessation 
of  the  customary  menstrual  discharge,  and  it  is  of  great  importance, 
as  forming  the  only  reliable  guide  for  calculating  the  probable  period 
of  delivery.  In  women  who  have  been  previously  perfectly  regular, 
in  whom  there  is  no  morbid  cause  which  is  likely  to  have  produced 
suppression,  the  non-appearance  of  the  catamenia  may  be  taken  as 
strong,  presumptive  evidence  of  the  existence  of  pregnancy;  but  it 
can  never  be  more  than  this,  unless  verified  and  strengthened  by 
other  signs,  inasmuch  as  there  are  many  conditions  besides  pregnancy 
which  may  lead  to  its  non-appearance.  Thus  exposure  to  cold, 
mental  emotion,  general  debility,  especially  when  connected  with 
incipient  phthisis,  may  all  have  this  effect.  Mental  impressions  are 
peculiarly  liable  to  mislead  in  this  respect.  It  is  far  from  uncommon 
in  newly-married  women  to  find  that  menstruation  ceases  for  one  or 
more  periods,  either  from  the  general  disturbance  of  the  system  con- 
nected with  the  married  life,  or  from  a  desire  on  the  part  of  the 
patient  to  find  herself  pregnant.  Also  in  unmarried  women,  who 
have  subjected  themselves  to  the  risk  of  impregnation,  mental  emo- 
tion and  alarm  often  produce  the  same  result. 

Menstruation  during  Pregnancy. — A  further  source  of  uncertainty 
exists  in  the  fact,  that  in  certain  cases  menstruation  may  go  on  for 
one  or  more  periods  after  conception,  or  even  during  the  whole 
pregnancy.  The  latter  occurrence  is  certainly  of  extreme  rarity, 
but  one  or  two  instances  are  recorded  by  Perfect,  Churchill,  and 
other  writers  of  authority,  and  therefore  its  possibility  must  be 
admitted.  The  former  is  much  less  uncommon,  and  instances  of  it 
have  probably  come  under  the  observation  of  most  practitioners. 
The  explanation  is  now  well  understood.  During  the  early  months 
of  gestation,  when  the  ovurn  is  not  yet  sufficiently  advanced  in  growth 
to  fill  the  whole  uterine  cavity,  there  is  a  considerable  space  between 
the  decidua  reflexa  which  surrounds  it,  and  the  decidua  vera  lining 
the  uterine  cavity.  It  is  from  this  free  surface  of  the  decidua  vera 
that  the  periodical  discharge  comes,  and  there  is  not  only  ample 
surface  for  it  to  come  from,  but  a  free  channel  for  its  escape  through 
the  os  uteri.  After  the  third  month  the  decidua  reflexa  and  the 
decidua  vera  blend  together,  and  the  space  between  them  disappears. 
Menstruation  after  this  time  is,  therefore,  much  more  difficult  to 
account  for.  It  is  probable  that,  in  many  supposed  cases,  occasional 
losses  of  blood  from  other  sources,  such  as  placenta  praevia,  an  abraded 
cervix  uteri,  or  a  small  polypus,  have  been  mistaken  for  true  men- 
struation. If  the  discharge  really  occurs  periodically  after  the  third 
month,  it  can  only  come  from  the  canal  of  the  cervix.  The  occurrence, 
however,  is  so  rare,  that  if  a  woman  is  menstruating  regularly  and 
normally,  who  believes  herself  to  be  m&re  than  four  months  advanced 
in  pregnancy,  we  are  justified  ipso  facto  in  negativing  her  supposition. 
In  an  unmarried  woman  all  statements  as  to  regularity  of  menstrua- 
tion are  absolutely  valueless,  for,  in  such  cases,  nothing  is  more 
common  than  for  the  patient  to  make  false  statements  for  the  express 
purpose  of  deception. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  135 

Pregnancy  ichen  Menstruation  is  Normally  Absent.- — Conception 
may  unquestionably  occur  when  menstruation  is  normally  absent. 
This  is  far  from  uncommon  in  women  daring  lactation,  when  the 
function  is  in  abeyance,  and  who  therefore  have  no  reliable  data  for 
calculating  the  true  period  of  their  delivery.  Authentic  cases  are 
also  recorded  in  which  young  girls  have  conceived  before  menstrua- 
tion is  established,  and  in  which  pregnancy  has  occurred  after  the 
change  of  life. 

Estimate  of  its  Diagnostic,  Value. — Taking  all  these  facts  into  ac- 
count, we  can  only  look  upon  the  cessation  of  menstruation  as  a  fairly 
presumptive  sign  of  pregnancy  in  women  in  whom  there  is  no  clear 
reason  to  account  for  it,  but  one  which  is  undoubtedly  of  great  value 
in  assisting  our  diagnosis. 

Sympathetic  Disturbances. — Shortly  after  conception  various  sym- 
pathetic disturbances  of  the  system  occur,  and  it  is  only  very  excep- 
tionally that  these  are  not  established.  They  are  generally  most 
developed  in  women  of  highly  nervous  temperament ;  and  they  are, 
therefore,  most  marked  in  patients  in  the  upper  classes  of  society,  in 
whom  this  class  of  organization  is  most  common. 

Morning  Sickness. — Amongst  the  most  frequent  of  these  are  various 
disorders  of  the  gastro-intestinal  canal.  Nausea  or  vomiting  is  very 
common ;  and  as  it  is  generally  felt  on  first  rising  from  the  recum- 
bent position,  it  is  popularly  known  amongst  women  as  the  "  morn- 
ing sickness."  It  sometimes  commences  almost  immediately  after 
conception,  but  more  frequently  not  until  the  second  month,  and  it 
rarely  lasts  after  the  fourth  month.  Generally  there  is  nausea  rather 
than  actual  vomiting.  The  woman  feels  sick  and  unable  to  eat  her 
breakfast,  and  often  brings  up  some  glairy  fluid.  In  other  cases,  she 
actually  vomits ;  and  sometimes  the  sickness  is  so  excessive  as  to 
resist  all  treatment,  seriously  to  affect  the  patient's  health,  and  even 
imperil  her  life.  These  grave  forms  of  the  affection  will  require 
separate  consideration. 

Cause  of  the  Sickness. — Very  different  opinions  have  been  held  as 
to  the  cause  of  morning  sickness.  Dr.  Henry  Bennet  believes  that, 
when  at  all  severe,  it  is  always  associated  with  congestion  and  inflam- 
mation of  the  cervix  uteri.  Dr.  Graily  Hewitt  maintains  that  it  de- 
pends entirely  on  flexion  of  the  uterus,  producing  irritation  of  the 
uterine  nerves  at  the  seat  of  the  flexion,  and  consequent  sympathetic 
vomiting.  This  theory,  when  broached  at  the  Obstetrical  Society, 
was  received  with  little  favor ;  it  seems  to  me  to  be  sufficiently  dis- 
proved by  the  fact,  which  I  believe  to  be  certain,  that  more  or  less 
nausea  is  a  normal  and  nearly  constant  phenomenon  in  pregnancy, 
for  it  is  difficult  to  believe  that  nearly  every  pregnant  woman  has  a 
flexed  uterus.  The  generally  received  explanation  is,  probably,  the 
correct  one,  viz.,  that  nausea,  as  well  as  other  forms  of  sympathetic 
disturbance,  depends  on  the  stretching  of  the  uterine  fibres  by  the 
growing  ovum,  and  consequent  irritation  of  the  uterine  nerves.  It 
is,  therefore,  one,  and  only  one,  of  the  numerous  reflex  phenomena 
naturally  accompanying  pregnancy.  It  is  an  old  observation  that 
when  the  sickness  of  pregnancy  is  entirely  absent,  other,  and  gene- 


136  PREGNANCY. 

rally  more  distressing,  sympathetic  derangements  are  often  met  with, 
such  as  a  tendency  to  syncope.  Dr.  Bedford1  has  laid  especial  stress 
on  this  point,  and  maintains  that  under  such  circumstances  women 
are  peculiarly  apt  to  miscarry. 

Other  derangements  of  the  digestive  functions,  depending  on  the 
same  cause,  are  not  uncommon,  such  as  excessive  or  depraved  appe- 
tite, the  patient  showing  a  craving  for  strange  and  even  disgusting 
articles  of  diet.  These  cravings  may  be  altogether  irresistible,  and 
are  popularly  known  as  "  longings."  Of  a  similar  character  is  the 
disturbed  condition  of  the  bowels  frequently  observed,  leading  to 
constipation,  diarrhoea,  and  excessive  flatulence. 

Other  Sympathetic  Phenomena. — Certain  glandular  sympathies  may 
be  developed,  one  of  the  most  common  being  an  excessive  secretion 
from  the  salivary  glands.  A  tendency  to  syncope  is  not  infrequent, 
rarely  proceeding  to  actual  fainting,  but  rather  to  that  sort  of  partial 
syncope,  unattended  with  complete  loss  of  consciousness,  which  the 
older  authors  used  to  call  "lypothemia."  This  often  occurs  in  women 
who  show  no  such  tendency  at  other  times,  and,  when  developed  to 
any  extent,  it  forms  a  very  distressing  accompaniment  of  pregnancy. 
Toothache  is  common,  and  is  not  rarely  associated  with  actual  caries 
of  the  teeth.  When  any  of  these  phenomena  are  carried  to  excess  it 
is  more  than  probable  that  some  morbid  condition  of  the  uterus 
exists,  which  increases  the  local  irritation  producing  them. 

Mental  Peculiarities. — Mental  phenomena  are  very  general.  An 
undue  degree  of  despondency,  utterly  beyond  the  patient's  control, 
is  far  from  uncommon ;  or  a  change  which  renders  the  bright  and 
good-tempered  woman  fractious  and  irritable;  or  even  the  more  for- 
tunate, but  less  common  change,  by  which  a  disagreeable  disposition 
becomes  altered  for  the  better. 

Diagnostic  Value. — All  these  phenomena  of  exalted  nervous  suscep- 
tibility are  but  of  slight  diagnostic  value.  They  may  be  taken  as 
corroborating  more  certain  signs,  but  nothing  more;  and  they  are 
chiefly  interesting  from  their  tendency  to  be  carried  to  excess  and  to 
produce  serious  disorders. 

Mammary  chanyes. — Certain  changes  in  the  mammae  are  of  early 
occurrence,  dependent,  no  doubt,  on  the  intimate  sympathetic  rela- 
tions at  all  times  existing  between  them  and  the  uterine  organs,  but 
chiefly  required  for  the  purpose  of  preparing  for  the  important  func- 
tion of  lactation,  which,  on  the  termination  of  pregnancy,  they  have 
to  perform. 

Chanyes  in  the  Areolsp. — Generally  about  the  second  month  of  preg- 
nancy the  breasts  become  increased  in  size  and  tender.  As  preg- 
nancy advances  they  become  much  larger  and  firmer,  and  blue  veins 
may  be  seen  coursing  over  them.  The  most  characteristic  changes 
are  about  the  nipples  and  areolse.  The  nipples  become  turgid,  and 
are  frequently  covered  with  minute  branny  scales,  formed  by  the 
dessication  of  sero-lactescent  fluid  oozing  from  them.  The  areolae  be- 
come greatly  enlarged  and  darkened  from  the  deposit  of  pigment 

1  Diseases  of  Women  and  Children,  p.  551. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 


137 


(Fig.  T-i).  The  extent  and  degree  of  this  discoloration  vary  much  in 
different  women.  In  fair  women  it  may  be  so  slight  as  to  be  hardly 
appreciable;  while  in  dark  women  it  is  generally  exceedingly  charac- 
teristic, sometimes  forming  a  nearly  black  circle  extending  over  a 


FIG.  74. 


Appearance  of  the  Areola  in  Pregnancy. 

great  part  of  the  breast.  The  areola  becomes  moist  as  well  as  dark 
in  appearance  and  is  somewhat  swollen,  and  a  number  of  small  tuber- 
cles are  developed  upon  it,  forming  a  circle  of  projections  around  the 
nipple.  These  tubercles  are  described  by  Montgomery  as  being  inti- 
mately connected  with  the  lactiferous  ducts,  some  of  which  may  oc- 
casionally be  traced  into  them  and  seem  to  open  on  their  summits. 
As  pregnancy  advances  they  increase  in  size  and  number.  During 
the  latter  months  what  has  been  called  "the  secondary  areola"  is 
produced,  and  when  well  marked  presents  a  very  characteristic  ap- 
pearance. It  consists  of  a  number  of  minute  discolored  spots  all 
round  the  outer  margin  of  the  areola  where  the  pigmentation  is 
fainter,  and  which  are  generally  described  as  resembling  spots  from 
which  the  color  had  been  discharged  by  a  shower  of  water-drops. 
This  change,  like  the  darkening  of  the  primary  areola,  is  most  marked 
in  brunettes.  At  this  period,  especially  in  women  whose  skin  is  of 
fine  texture,  whitish  silvery  streaks  are  often  seen  on  the  breasts. 
They  are  produced  by  the  stretching  of  the  cutis  vera,  and  are  per- 
manent. 

By  pressure  on  the  breasts  a  small  drop  of  serous-looking  fluid 
can  very  generally  be  pressed  out  from  the  nipple  often  as  early  as 
the  third  month,  and  on  microscopic  examination  rnilk  and  cholos- 
trum  globules  can  be  seen  in  it. 
10 


138  PREGNANCY. 

Diagnostic  Value  of  Mammary  Changes. — The  diagnostic  value  of 
these  mammary  changes  has  been  variously  estimated.  When  well 
marked  they  are  considered  by  Montgomery  to  be  certain  signs  of 
pregnancy.  To  this  statement,  however,  some  important  limitations 
must  be  made.  In  women  who  have  never  borne  children  they,  no 
doubt,  are  so ;  for,  although  various  uterine  and  ovarian  diseases 
produce  some  darkening  of  the  areola,  they  certainly  never  produce 
the  well-marked  changes  above  described.  In  multipart,  however, 
the  areolae  often  remain  permanently  darkened,  and  in  them  these 
signs  are  much  less  reliable.  In  first  pregnancies  the  presence  of 
milk  in  the  breasts  may  be  considered  an  almost  certain  sign,  and  it 
is  one  which  I  have  rarely  failed  to  detect  even  from  a  comparatively 
early  period.  It  is  true  that  there  are  authenticated  instances  of 
non-pregnant  women  having  an  abundant  secretion  of  milk  estab- 
lished from  mammary  irritation.  Thus  Baudelocque  presented  to 
the  Academy  of  Surgery  of  Paris  a  young  girl,  eight  years  of  age, 
who  had  nursed  her  little  brother  for  more  than  a  month.  Dr.  Tan- 
ner states — I  do  not  know  on  what  authority — that  "it  is  not  uncom- 
mon in  Western  Africa  for  young  girls  who  have  never  been  preg- 
nant to  regularly  employ  themselves  in  nursing  the  children  of  others, 
the  mammae  being  excited  to  action  by  the  application  of  the  juice 
of  one  of  the  euphorbiaceae."  Lacteal  secretion  has  even  been  noticed 
in  the  male  breast.  But  these  exceptions  to  the  general  rule  are  so 
uncommon  as  merely  to  deserve  mention  as  curiosities ;  and  I  have 
almost  never  been  deceived  in  diagnosing  a  first  pregnancy  from  the 
presence  of  even  the  minutest  quantity  of  lacteal  secretion  in  the 
breasts,  although  even  then  other  corroborative  signs  should  always 
be  sought  for.  In  multiparae  the  presence  of  milk  is  by  no  means 
so  valuable,  for  it  is  common  for  milk  to  remain  in  the  mammas  long 
after  the  cessation  of  lactation,  even  for  several  years.  Tyler  Smith 
correctly  says  that  "suppression  of  the  milk  in  persons  who  are 
nursing  and  liable  to  impregnation  is  a  more  valuable  sign  of  preg- 
nancy than  the  converse  condition."  This  is  an  observation  I  have 
frequently  corroborated. 

As  a  diagnostic  sign,  therefore,  the  mammary  appearances  are  of 
great  importance  in  primiparae,  and  when  well  marked  they  are  sel- 
dom likely  to  deceive.  They  are  specially  important  when  we  sus- 
pect pregnancy  in  the  unmarried,  as  we  can  easily  make  an  excuse 
to  look  at  the  breast  without  explaining  to  the  patient  the  reason ; 
and  a  single  glance,  especially  if  the  patient  be  dark-complexioned, 
may  so  far  strengthen  our  suspicion  as  to  justify  a  more  thorough  ex- 
amination. In  married  multiparae  they  are  less  to  be  depended  upon. 
Other  Pigmentary  Changes. — In  connection  with  this  subject  may 
be  mentioned  various  irregular  deposits  of  pigment  which  are  fre- 
quently observed.  The  most  common  is  a  dark  brownish  or  yellow- 
ish line  starting  from  the  pubes  and  running  up  to  the  centre  of  the 
abdomen,  sometimes  as  far  as  the  umbilicus  only,  at  others  forming 
an  irregular  ring  round  the  umbilicus,  and  reaching  to  the  epigas- 
trium. [It  is  well  marked  in  pregnant  women  of  the  African  race, 
even  in  those  of  quite  a  dark  shade  of  skin.  This  line  is  narrower 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  130 

as  a  rule,  than  in  the  white,  but  darker. — ED.]  It  is,  however,  of 
very  uncertain  occurrence,  being  well  marked  in  some  women,  while 
in  others  it  is  entirely  absent.  Patches  of  darkened  skin  are  often 
observed  about  the  face,  chiefly  on  the  forehead,  and  this  bronzing 
sometimes  gives  a  very  peculiar  appearance.  Joulin  states  that  it 
only  occurs  on  parts  of  the  face  exposed  to  the  sun,  and  that  it  is 
therefore  most  frequently  observed  in  women  of  the  lower  order, 
who  are  freely  exposed  to  atmospheric  influences.  These  pigment- 
ary changes  are  of  small  diagnostic  value,  and  may  continue  for  a 
considerable  time  after  delivery. 

Enlargement  of  the  Abdomen. — The  progressive  enlargement  of  the 
abdomen,  and  the  size  of  the  gravid  uterus  at  various  periods  of 
pregnancy,  as  well  as  the  method  of  examination  by  means  of  ab- 
dominal palpation,  have  already  been  described  (pp.  114  and  124). 

We  will  now  consider  the  well-known  phenomena  produced  by 
the  movements  of  the  foetus  in  utero,  which  are  so  familiar  to  all 
pregnant  women.  These,  no  doubt,  take  place  from  the  earliest 
psriod  of  foetal  life  at  which  the  muscular  tissue  of  the  foetus  is  suffi- 
ciently developed  to  admit  of  contraction,  but  they  are  not  felt  by 
the  mother  until  somewhere  about  the  sixteenth  week  of  utero-ges- 
tation,  the  precise  period  at  which  they  are  perceived  varying  con- 
siderably in  different  cases.  The  error  of  the  law  on  this  subject, 
which  supposes  the  child  not  to  be  alive,  or  "  quick,"  until  the  mother 
feels  its  movements,  is  well  known,  and  has  frequently  been  protested 
against  by  the  medical  profession.  The  so-called  quickening — which 
certainly  is  felt  very  suddenly  by  some  women — is  believed  to  depend 
on  the  rising  of  the  uterine  tumor  sufficiently  high  to  permit  of  the 
impulse  of  the  foetus  being  transmitted  to  the  abdominal  walls  of  the 
mother,  through  the  sensory  nerves  of  which  its  movements  become 
appreciable.  The  sensation  is  generally  described  as  being  a  feeble 
fluttering,  which,  when  first  felt,  not  unfrequently  causes  unpleasant 
nervous  sensations.  As  the  uterus  enlarges,  the  movements  become 
more  and  more  distinct,  and  generally  consist  of  a  series  of  sharp 
blows  or  kicks,  sometimes  quite  appreciable  to  the  naked  eye,  and 
causing  distinct  projections  of  the  abdominal  walls.  Their  force  and 
frequency  will  also  vary  during  pregnancy  according  to  circum- 
stances. At  times  they  are  very  frequent  and  distressing ;  at  others, 
the  foetus  seems  to  be  comparatively  quiet,  and  they  may  even  not 
be  felt  for  several  days  in  succession,  and  thus  unnecessary  fears  as 
to  the  death  of  the  foetus  often  arise.  The  state  of  the  mother's 
health  has  an  undoubted  influence  upon  them.  They  are  said  to 
increase  in  force  after  a  prolonged  abstinence  from  food,  or  in  certain 
positions  of  the  body.  It  is  certain  that  causes  interfering  with  the 
vitality  of  the  foetus  often  produce  very  irregular  and  tumultuous 
movements.  They  can  be  very  readily  felt  by  the  accoucheur  on 
palpating  the  abdomen,  and  sometimes,  in  the  latter  months,  so  dis- 
tinctly as  to  leave  no  doubt  as  to  the  existence  of  pregnancy.  They 
can  also  generally  be  induced  by  placing  one  hand  on  each  side  of 
the  abdomen  and  applying  gentle  pressure,  which  will  induce  foetal 
motion,  that  can  be  easily  appreciated. 


140  PREGNANCY. 

The  Diagnostic  Yalue  of  Foetal  Movements. — >As  a  diagnostic  sign 
the  existence  of  foetal  movements  lias  always  held  a  high  place,  but 
care  should  be  taken  in  relying  on  it.  It  is  certain  that  women  are 
themselves  very  often  in  error,  and  fancy  they  feel  the  movements 
of  a  foetus  when  none  exists,  being  probably  deceived  by  irregular 
contractions  of  the  abdominal  muscles,  or  flatus  within  the  bowels. 
They  may  even  involuntarily  produce  such  mtra-abdominal  move- 
ments as  may  readily  deceive  the  practitioner.  Of  course,  in  advanced 
pregnancy,  when  the  foetal  movements  are  so  marked  as  to  be  seen  as 
well  as  felt,  a  mistake  is  hardly  possible,  and  they  then  constitute  a 
certain  sign.  But  in  such  cases  there  is  an  abundance  of  other  indi- 
cations and  little  room  for  doubt.  In  questionable  cases,  and  at  an 
earlier  period  of  pregnancy,  the  fact  that  movements  are  not  felt 
must  not  be  taken  as  a  proof  of  the  non-existence  of  pregnancy,  for 
they  may  be  so  feeble  as  not  to  be  perceptible,  or  they  may  be  absent 
for  a  considerable  period. 

Intermittent  Uterine  Contractions. — Braxton  Hicks1  has  directed 
attention  to  the  value,  from  a  diagnostic  point  of  view,  of  intermittent 
contractions  of  the  uterus  during  pregnancy.  After  the  uterus  is 
sufficiently  large  to  be  felt  by  palpation,  if  the  hand  be  placed  over 
it,  and  it  be  grasped  for  a  time  without  using  any  friction  or  pressure, 
it  will  be  observed  to  distinctly  harden  in  a  manner  that  is  quite 
characteristic.  This  intermittent  contraction  occurs  every  five  or  ten 
minutes,  sometimes  oftener,  rarely  at  longer  intervals.  The  fact  that 
the  uterus  did  contract  in  this  way  had  been  previously  described, 
more  especially  by  Tyler  Smith,  who  ascribed  it  to  peristaltic  action. 
But  it  is  certain  that  no  one,  before  Dr.  Hicks,  had  pointed  out  the 
fact  that  such  contractions  were  constant  and  normal  concomitants 
of  pregnancy,  continuing  during  the  whole  period  of  utero-gestation, 
and  forming  a  ready  and  reliable  means  of  distinguishing  the  uterine 
tumor  from  other  abdominal  enlargements.  Since  reading  Dr.  Hicks's 
paper  I  have  paid  considerable  attention  to  this  sign,  which  I  have 
never  failed  to  detect,  even  in  the  retroverted  gravid  uterus  contained 
entirely  in  the  pelvic  cavity,  and  I  arn  disposed  entirely  to  agree 
with  him  as  to  its  great  value  in  diagnosis.  If  the  hand  be  kept 
steadily  on  the  uterus,  its  alternate  hardening  and  relaxation  can  be 
appreciated  with  the  greatest  ease.  The  advantages  which  this  sign 
has  over  the  foetal  movements  are  that  it  is  constant,  that  it  is  not 
liable  to  be  simulated  by  anything  else,  and  that  it  is  independent  of 
the  life  of  the  child,  being  equally  appreciable  when  the  uterus  con- 
tains a  degenerated  ovum  or  dead  foetus.  The  only  condition  likely 
to  give  rise  to  error  is  an  enlargement  of  the  uterus  in  consequence 
of  contents  other  than  the  results  of  conception,  such  as  retained 
menses,  or  a  polypus.  The  history  of  such  cases — which  are  more- 
over of  extreme  rarity — would  easily  prevent  any  mistake.  As  a 
corroborative  sign  of  pregnancy,  therefore,  I  should  give  these  inter- 
mittent contractions  a  high  place.  [These  intermittent  contractions 
are  in  rare  instances  accompanied  by  a  sense  of  pain,  and  would 

1  Obst.  Trans,  v.  13. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  141 

appear  to  threaten  miscarriage.  We  saw  one  case  in  which  they 
persisted  for  three  weeks,  and  gradually  subdsidecl  under  an  opiate 
treatment. — ED.] 

Vaginal  Signs  of  Pregnancy. — The  vaginal  signs  of  pregnancy  are 
of  considerable  importance  in  diagnosis.  They  are  chiefly  the  changes 
which  may  be  detected  in  the  cervix,  and  the  so-called  balloUement, 
which  depends  on  the  mobility  of  the  foetus  in  the  liquor  amnii. 

Softening  of  the  Cervix. — The  alterations  in  the  density  and  appa- 
rent length  of  the  cervix  have  been  already  described  (p.  126).  When 
pregnancy  has  advanced  beyond  the  fifth  month  the  peculiar  velvety 
softness  of  the  cervix  is  very  characteristic,  and  affords  a  strong 
corroborative  sign,  but  one  which  it  would  be  unsafe  to  rely  on  by 
itself,  inasmuch  as  very  similar  alterations  may  be  produced  by 
various  causes.  When,  however,  in  a  supposed  case  of  pregnancy 
advanced  beyond  the  period  indicated,  the  cervix  is  found  to  be 
elongated,  dense,  and  projecting  into  the  vaginal  canal,  the  non- 
existence  of  pregnancy  may  be  safely  inferred.  Therefore  the  nega- 
tive value  of  this  sign  is  of  more  importance  than  the  positive. 

Ballottement,  when  distinctly  made  out,  is  a  very  valuable  indica- 
tion of  pregnancy.  It  consists  in  the  displacement,  by  the  examining 
finger,  of  the  foetus,  which  floats  up  in  the  liquor  amnii,  and  falls 
back  again  on  the  tip  of  the  finger  with  a  slight  tap  which  is 
exceedingly  characteristic. 

Method  of  Examination. — In  order  to  practise  it  most  easily,  the 
patient  is  placed  on  a  couch  or  bed  in  a  position  midway  between 
sitting  and  lying,  by  which  the  vertical  diameter  of  the  uterine 
cavity  is  brought  into  correspondence  with  that  of  the  pelvis.  Two 
fingers  of  the  right  hand  are  then  passed  high  up  into  the  vagina  in 
front  of  the  cervix.  The  uterus  being  now  steadied  from  without 
by  the  left  hand,  the  intravaginal  fingers  press  the  uterine  wall 
suddenly  upwards,  when,  if  pregnancy  exist,  the  foetus  is  displaced, 
and  in  a  moment  falls  back  again,  imparting  a  distinct  impulse  to 
the  fingers.  When  easily  appreciable  it  may  be  considered  as  a 
certain  sign,  for  although  an  ante-flexed  fundus,  or  a  calculus  in  the 
bladder,  may  give  rise  to  somewhat  similar  sensations,  the  absence 
of  other  indications  of  pregnancy  would  readily  prevent  error.  Bal- 
lottement  is  practised  between  the  fourth  and  seventh  months.  Be- 
fore the  former  time  the  foetus  is  too  small,  while  at  a  later  period 
it  is  relatively  too  large,  and  can  no  longer  be  easily  made  to  rise 
upwards  in  the  surrounding  liquor  amnii.  The  absence  of  ballotte- 
ment  must  not  be  taken  as  proving  the  non-existence  of  pregnancy, 
for  it  may  be  inappreciable  from  a  variety  of  causes,  such  as  abnor- 
mal presentations,  or  the  implantation  of  the  placenta  upon  the 
cervix  uteri. 

Vaginal  Pulsation. — There  are  also  some  other  vaginal  signs  of 
pregnancy  of  secondary  consequence.  Amongst  these  is  the  vaginal 
pulsation,  pointed  out  by  Osiander,  resulting  from  the  enlargement 
of  the  vaginal  arteries,  which  may  sometimes  be  felt  beating  at  an 
early  period.  Often  this  pulsation  is  very  distinct,  at  other  times  it 


142  PREGNANCY. 

cannot  be  felt  at  all,  and  it  is  altogether  unreliable,  as  a  similar  pul- 
sation may  be  felt  in  various  uterine  diseases. 

Uterine  Fluctuation. — Dr.  Rasch  has  drawn  attention  to  a  previously 
undescribed  sign  which  he  believes  to  be  of  importance  in  the  diag- 
nosis of  early  pregnancy.1  It  consists  in  the  detection  of  fluctuation 
through  the  anterior  uterine  wall,  depending  on  the  presence  of  the 
liquor  amnii.  In  order  to  make  this  out,  two  fingers  of  the  right 
hand  must  be  used,  as  in  ballottement,  while  the  uterus  is  steadied 
through  the  abdomen.  Dr.  Rasch  states  that  by  this  means  the 
enlarged  uterus  in  pregnancy  can  easily  be  distinguished  from  the 
enlargement  depending  on  other  causes,  and  that  fluctuation  can 
always  be  felt  as  early  as  the  second  month.  If  it  is  associated  with 
suppressed  menstruation  and  darkened  areolae,  he  considers  it  a 
certain  sign.  In  order  to  detect  it,  however,  considerable  experience 
in  making  vaginal  examinations  is  essential,  and  it  can  hardly  be 
depended  on  for  general  use. 

Alteration  in  Color  of  the  Vagina. — A  peculiar  deep  violet  hue  of 
the  vaginal  mucous  membrane  was  relied  on  by  Jacquemier  and 
Kliige  as  affording  a  readily-observed  indication  of  pregnancy.  In 
most  cases  it  is  well  marked  ;  sometimes,  indeed,  the  change  of  color 
is  very  intense,  and  it  evidently  depends  on  the  congestion  produced 
by  pressure  of  the  enlarged  uterus.  The  same  effect,  however,  is 
constantly  seen  where  similar  pressure  is  effected  by  large  fibroid 
tumors  of  the  uterus,  and,  therefore,  for  diagnostic  purposes  it  is 
valueless. 

Auscultatory  Signs  of  Pregnancy. — By  far  the  most  important 
signs  are  those  which  can  be  detected  by  abdominal  auscultation,  and 
one  of  these — the  hearing  of  the  foetal  heart-sounds — forms  the  only 
sign  which  per  se,  and  in  the  absence  of  all  others,  is  perfectly  reliable. 

Discovery  of  Foetal  Auscultation. — The  fact  that  the  sounds  of  the 
foetal  heart  are  audible  during  advanced  pregnancy  was  first  pointed 
out  by  Mayor  of  Geneva  in  1818,  arid  the  main  facts  in  connection 
with  foetal  auscultation  were  subsequently  worked  out  by  Kerga- 
radec,  Naegele,  Evory  Kennedy,  and  other  observers.  The  pulsations 
first  become  audible,  as  a  rule,  in  the  course  of  the  fifth  month,  or 
about  the  middle  of  the  fourth  month.  In  exceptional  circumstances, 
and  by  practised  observers,  they  have  been  heard  earlier.  Depaul 
believes  that  he  detected  them  as  early  as  the  eleventh  week,  and 
Routh  has  also  detected  them  at  an  early  period  by  vaginal  stetho- 
scopy,  which,  however,  for  obvious  reasons,  cannot  be  ordinarily 
employed.  Naegele  never  heard  them  before  the  eighteenth  week, 
more  generally  at  the  end  of  the  twentieth,  and  for  practical  purposes 
the  pregnancy  must  be  advanced  to  the  fifth  month  before  we  can 
reasonably  expect  to  detect  them.  From  this  period  up  to  term  they 
can  almost  always  be  heard,  if  not  at  the  first  attempt,  at  least  after- 
wards, to  a  certainty,  if  we  have  the  opportunity  of  making  repeated 
examinations.  Accidental  circumstances,  such  as  the  presence  of  an 
unusual  amount  of  flatus  in  the  intestines,  may  deaden  the  sounds  for 

1  Brit.  Med.  Journ.,  vol.  ii.  1873. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  143 

a  time,  but  not  permanently.  Depaul  only  failed  to  hear  them  in  8 
cases  out  of  906  examined  during  the  last  three  months  of  pregnancy: 
and  out  of  180  cases,  which  Dr.  Anderson  of  Glasgow  carefullv 
examined,  he  only  failed  in  12,  and  in  each  of  these  the  child  was 
still-born.  They,  therefore,  form  not  only  a  most  certain  indication 
of  pregnancy,  but  of  the  life  of  the  foetus  also. 

Description  of  the  Sound. — The  sound  has  been  always  likened  to 
the  double  tic-tac  of  a  watch  heard  through  a  pillow,  which  it  closely 
resembles.  It  consists  of  twro  beats,  separated  by  a  short  interval, 
the  first  being  the  loudest  and  most  distinct,  the  second  being  some- 
times inaudible.  The  rapidity  of  the  fcetal  pulsations  forms  an 
important  means  of  distinguishing  them  from  transmitted  maternal 
pulsations,  with  which  they  might  be  confounded.  Their  average 
number  is  stated  by  Slater,  who  made  numerous  observations  on  this 
point,  to  be  132,  but  sometimes  they  reach  as  high  as  140,  and  some- 
times as  low  as  120.  It  will  thus  be  seen  that  the  pulsations  are 
always  much  more  rapid  than  those  of  the  mother's  heart,  unless, 
indeed,  the  latter  be  unduly  accelerated  by  transient  mental  emotion 
or  disease.  To  avoid  mistakes,  whenever  the  foetal  heart  is  heard  its 
rate  of  pulsation  should  be  carefully  counted,  and  compared  with 
that  of  the  mother's  pulse ;  if  the  rates  differ,  we  may  be  sure  that 
no  error  has  been  made.  The  rapidity  of  the  foetal  pulsations,  re- 
mains, as  a  rule,  the  same  during  the  whole  period  of  pregnancy, 
while  their  intensity  gradually  increases.  They  may,  however,  be 
temporarily  increased  or  diminished  in  frequency  by  disturbing 
causes,  such  as  the  pressure  of  the  stethoscope,  which,  exciting 
tumultuous  movements  of  the  foetus,  may  induce  greatly-increased 
frequency  of  its  heart-beats.  So  also  during  labor,  after  the  escape 
of  the  liquor  amnii,  when  the  contractions  of  the  uterus  have  a  very 
distinct  influence  on  the  foetus,  they  may  be  greatly  modified  An 
acceleration  or  irregularity  of  the  pulsations,  made  out  in  the  course 
of  a  prolonged  labor,  may  thus  be  of  great  practical  importance,  by 
indicating  the  necessity  for  prompt  interference.  Similar  alterations, 
associated  with  tumultuous  and  unusual  foetal  movements  felt  by  the 
mother  towards  the  end  of  pregnancy,  may  point  to  danger  to  the 
life  of  the  foetus  during  the  latter  months,  and  may  even  justify  the 
induction  of  premature  labor.  This  is  especially  the  case  in  women 
who  have  previously  given  birth  to  a  succession  of  dead  children 
owing  to  disease  of  the  placenta,  and,  in  them,  careful  and  frequently 
repeated  auscultations  may  warn  us  of  the  impending  danger. 

Supposed  difference  of  Rapidity  according  to  the  Sex  of  Foetus. — 
The  rapidity  of  the  fcetal  heart  has  been  supposed  by  some  to  afford 
a  means  of  determining  the  sex  of  the  child  before  birth.  Franken- 
hauser,  who  first  directed  attention  to  this  point,  is  of  opinion  that 
the  average  rate  of  pulsations  of  the  heart  are  considerably  less  in 
male  than  in  female  children,  averaging  124  in  the  minute  in  the 
former,  as  against  144  in  the  latter.  Steinbach  makes  the  difference 
somewhat  less,  viz.,  131  for  males,  and  138  for  females.  He  pre- 
dicted the  sex  correctly  by  this  means  in  45  out  of  57  cases,  while 
Frankenhauser  was  correct  in  the  whole  50  cases  which  he  spe- 


144  PREGNANCY. 

ciallj  examined  with  reference  to  the  point.  Dr.  Hutton,  of  New- 
York,1  was  also  correct  in  7  cases  he  fixed  on  for  trial.  Devilliers 
found  the  difference  in  the  sexes  to  be  the  same  as  Steinbach ;  he 
attributes  it,  however,  to  the  size  and  weight,  rather  than  to  the  sex 
of  the  child,  and  believes  the  pulsations  to  be  least  numerous  in 
large  and  well-developed  children.  As  male  children  are  usually 
larger  than  female,  he  thus  explains  the  relatively  less  frequent  pul- 
sations of  their  hearts.  Dr.  Gumming,  of  Edinburgh,  also  believes 
that  the  weight  of  the  child  has  considerable  influence  on  the  fre- 
quency of  its  cardiac  pulsations,  so  that  a  large  female  child  may 
have  a  slower  pulse  than  a  small  male.2  The  point,  however,  is  more 
curious  than  practical,  and  the  rapidity  of  the  pulsations  certainly 
would  not  justify  any  positive  prediction  on  the  subject.  Circum- 
stances influencing  the  maternal  circulation  seem  to  have  no  influence 
on  that  of  the  foetus. 

Site  at  which  the  Sounds  are  heard. — The  foetal  heart-sounds  are 

fenerally  propagated  best  by  the  back  of  the  child,  and  are,  there- 
)re,  most  easily  audible  when  this  is  in  contact  with  the  anterior 
wall  of  the  uterus,  as  is  the  case  in  the  large  majority  of  pregnancies. 
When  the  child  is  placed  in  the  dorso-posterior  position,  the  sounds 
have  to  traverse  a  larger  amount  of  the  liquor  amnii,  and  are  further 
modified  by  the  interposition  of  the  foetal  limbs.  They  are,  there- 
fore, less  easily  heard  in  such  cases,  but  even  in  them  they  can  almost 
always  be  made  out.  As  the  foetus  most  frequently  lies  Avith  the 
occiput  over  the  brim  of  the  pelvis,  and  the  back  of  the  child  towards 
the  left  side  of  the  mother,  the  heart-sounds  are  usually  most  dis- 
tinctly audible  at  a  point  midway  between  the  umbilicus  and  the  left 
anterior-superior  spine  of  the  ilium.  In  the  next  most  common  posi- 
tion, in  which  the  back  of  the  child  lies  to  the  right  lumbar  region  of 
the  mother,  they  are  generally  heard  at  a  corresponding  point  at  the 
right  side,  but  in  this  case  they  are  frequently  more  readily  made 
out  in  the  right  flank,  being  then  transmitted  through  the  thorax  of 
the  child,  which  is  in  contact  with  the  side  of  the  uterus.  In  breech 
cases,  on  the  other  hand,  the  heart-sounds  are  generally  heard  most 
distinctly  above  the  umbilicus,  and  either  to  the  right  or  left,  accord- 
ing to  the  side  towards  which  the  back  of  the  child  is  placed.  It 
will  thus  be  seen  that  the  place  at  which  the  foetal  heart-sounds  are 
heard  varies  with  the  position  o'f  the  foetus ;  and  this,  when  combined 
with  the  information  derived  from  palpation,  affords  a  ready  means 
of  ascertaining  the  presentation  of  the  child  before  labor.  The  sounds 
are  only  audible  over  a  limited  space,  about  two  to  three  inches  in 
diameter ;  therefore,  if  we  fail  to  detect  them  in  one  place,  a  careful 
exploration  of  the  whole  uterine  tumor  is  necessary  before  we  are 
satisfied  that  they  cannot  be  heard. 

Sources  of  Fallacy. — The  only  mistake  that  is  likely  to  be  made  is 
taking  the  maternal  pulsations,  transmitted  through  the  uterine 
tumor,  for  those  of  the  foetal  heart.  A  little  care  will  easily  prevent 
this  error,  and  the  frequency  of  the  mother's  pulse  should  always  be 

1  New  York  Med.  Journ.,  July,  1872.  *  Edin.  Med.  Journ.,  1875. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  145 

ascertained  before  counting  the  supposed  foetal  pulsations.  If  these 
are  found  to  be  120  or  more,  while  the  mother's  pulse  is  only  70  or 
80,  no  mistake  is  possible.  If  the  latter  is  abnormally  quickened 
greater  care  may  be  necessary,  but  even  then  the  rate  of  pulsation  of 
each  will  be  dissimilar.  Braxton  Hicks1  has  pointed  out  that  in 
tedious  labor,  when  the  muscular  powers  of  the  mother  are  exhausted, 
the  muscular  subsurrus  may  produce  a  sound  closely  resembling  the 
foetal  pulsation ;  but  error  from  this  source  is  obviously  very  im- 
probable. 

Mode  of  practising  Auscultation.— in  listening  for  the  foetal  heart- 
sounds  the  patient  should  be  placed  on  her  back,  with  the  shoulders 
elevated  and  the  knees  flexed.  The  surface  of  the  abdomen  should 
be  uncovered,  and  an  ordinary  stethoscope  employed,  the  end  of 
which  must  be  pressed  firmly  on  the  tumor,  so  as  to  depress  the  ab- 
dominal walls.  The  most  absolute  stillness  is  necessary,  as  it  is  often 
far  from  easy  to  hear  the  sounds.  Sometimes,  after  failing  with  the 
ordinary  stethoscope,  I  have  succeeded  with  the  bin-aural,  which 
remarkably  intensifies  them.  [Dr.  Camman's  double  instrument 
answers  a  good  purpose. — ED.]  When  once  heard  they  are  most 
easily  counted  during  a  space  of  five  seconds,  as,  on  account  of  their 
frequency,  it  is  not  always  possible  to  follow  them  over  a  longer 
period. 

Value  of  this  Sign  of  Pregnancy. — When  the  foetal  heart-sounds 
are  heard  distinctly,  pregnancy  may  be  absolutely  and  certainly  diag- 
nosed. The  fact  that  we  do  not  hear  them  does  not,  however,  pre- 
clude the  possibility  of  gestation,  for  the  foetus  may  be  dead,  or  the 
sounds  temporarily  inaudible. 

Umbilical  Souffle. — There  are  some  other  sounds  heard  in  ausculta- 
tion which  are  of  very  secondary  diagnostic  value.  One  of  these  is 
the  so-called  umbilical  orfunic  souffle,  which  was  first  pointed  out  by 
Evory  Kennedy.  It  consists  of  a  single  blowing  murmur,  synchro- 
nous with  the.  foetal  heart  sounds,  and  most  distinctly  heard  in  the 
immediate  vicinity  of  the  point  where  these  are  most  audible.  Most 
authors  believe  it  to  be  produced  by  pressure  on  the  cord,  either 
when  it  is  placed  between  a  hard  part  of  the  foetus  and  the  uterine 
walls,  or  is  twisted  round  the  child's  neck.  Schroeder  and  Hecker 
detected  it  in  fourteen  or  fifteen  per  cent,  of  all  cases,  and  the  latter 
believed  it  to  be  caused  by  flexure  of  the  first  portion  of  the  cord 
near  the  umbilicus.  For  practical  purposes  it  is  quite  valueless,  and 
need  only  be  mentioned  as  a  phenomenon  which  an  experienced  aus- 
cultator  may  occasionally  detect. 

Uterine  Souffle. — The  uterine  souffle  is  a  peculiar  single  whizzing 
murmur  which  is  almost  always  audible  on  auscultation.  It  varies 
very  remarkably  in  character  and  position.  Sometimes  it  is  a  gentle 
blowing  or  even  musical  murmur ;  at  others  it  is  loud,  harsh,  and  scrap- 
ping ;  sometimes  continuous,  sometimes  intermittent.  It  may  also  be 
heard  at  any  point  of  the  uterus,  but  most  frequently  low  down,  and  to 
one  or  other  side  ;  more  rarely  above  the  umbilicus,  or  towards  the  fun- 

1  Obst.  Trans.,  vol.  xv. 


140  PREGNANCY. 

dus;  and  it  often  changes  its  position  so  as  to  be  heard  at  a  subsequent 
auscultation  at  a  point  where  it  was  previously  inaudible.  It  may 
be  heard  over  a  space  of  an  inch  or  two  only,  or,  in  some  cases,  over 
the  whole  uterine  tumor;  or  again,  it  may  sometimes  be  detected 
simultaneously  over  two  entirely  distinct  portions  of  the  uterus.  It 
is  generally  to  be  heard  earlier  than  the  foetal  heart-sounds,  often  as 
soon  as  the  uterus  rises  above  the  brim  of  the  pelvis,  and  it  can  almost 
always  be  detected  after  the  commencement  of  the  fourth  month. 
The  sound  becomes  curiously  modified  by  the  uterine  contractions 
during  labor,  becoming  louder  and  more  intense  before  the  pain  comes 
on,  disappearing  during  its  acme,  and  again  being  heard  as  it  goes 
off.  Hicks  attributes  to  a  similar  cause,  viz.,  the  uterine  contractions 
during  pregnancy,  the  frequent  variations  in  the  sound  which  are 
characteristic  of  it.1  The  uterine  souffle  is  also  audible  after  the 
death  of  the  foetus,  and  it  is  believed  by  some  to  be  modified  and  to 
become  more  continuously  harsh  when  that  event  has  taken  place. 

Theories  as  to  its  Cause. — Very  various  explanations  have  been 
given  of  the  causes  of  this  sound.  For  long  it  was  supposed  to  be 
formed  in  the  vessels  of  the  placenta,  and  hence  the  name  "placental 
souffle"  by  which  it  is  often  talked  of;  or  if  not  in  the  placenta,  in 
the  uterine  vessels  in  its  immediate  neighborhood.  The  non-placental 
origin  of  the  sound  is  sufficiently  demonstrated  by  the  fact  that  it 
may  be  heard  for  a  considerable  time  after  the  expulsion  of  the  pla- 
centa. Some  have  supposed  that  it  is  not  formed  in  the  uterus  at  all, 
but  in  the  maternal  vessels,  especially  the  aorta  and  the  iliac  arteries, 
owing  to  the  pressure  to  which  they  are  subjected  by  the  gravid 
uterus.  The  extreme  irregularity  of  the  sound,  its  occasional  disap- 
pearance, and  its  variable  site,  seem  to  be  conclusive  against  this 
view.  The  theory  which  refers  the  sound  to  the  uterine  vessels  is 
that  which  has  received  most  adherents,  and  which  best  meets  the 
facts  of  the  case ;  but  it  is  by  no  means  easy  or  even  possible  to 
account  for  the  exact  mode  of  its  production  in  them.  Each  of  the 
explanations  which  have  been  given  is  open  to  some  objection.  It 
is  far  from  unlikely  that  the  intermittent  contractions  of  the  uterine 
fibres,  which  are  known  to  occur  during  the  whole  course  of  preg- 
nancy, may  have  much  to  do  with  it,  by  modifying,  at  intervals,  the 
rapidity  of  the  circulation  in  the  vessels.  Its  production  in  this 
manner  may  also  be  favored  by  the  chlorotic  state  of  the  blood,  to 
which  Cazeaux  and  Scanzoni  are  inclined  to  attribute  an  important 
influence,  likening  it  to  the  anaemic  murmur  so  frequently  heard  in  the 
vessels  in  weakly  women. 

Diagnostic  Value. — From  a  diagnostic  point  of  view  the  uterine 
souffle  is  of  very  secondary  importance,  because  a  similar  sound  is 
very  generally  audible  in  large  fibroid  tumors  of  the  uterus,  and 
even  in  some  few  ovarian  tumors;  it  is,  therefore,  of  little  or  no 
value  in  assisting  us  to  decide  the  character  of  the  abdominal  enlarge- 
ment. The  supposed  dependence  of  the  sound  on  the  placental  cir- 
culation has  caused  its  site  to  be  often  identified  with  that  of  the 

1  Op.  cit.  p.  233. 


SIGNS    AND    SYMPTOMS    OF    PREGNANCY.  147 

placenta.  It  is,  however,  most  frequently  heard  at  the  lower  part 
of  the  uterus,  while  the  placenta  is  generally  attached  near  the 
fundus,  so  that  its  position  cannot  be  taken  as  any  safe  guide  in 
determining  the  situation  of  that  viscus. 

Sounds  produced  l>y  the  Movements  of  the  Foetus. — Occasionally,  in 
practising  auscultation,  irregular  sounds  of  brief  duration  may  be 
heard,  which  are  not  susceptible  of  accurate  description,  and  which 
doubtless  depend  on  the  sudden  movements  of  the  foetus  in  the 
liquor  amnii,  or  on  the  impact  of  its  limbs  on  the  uterine  walls. 
When  heard  distinctly  they  are  characteristic  of  pregnancy;  and 
they  may  be  sometimes  heard  when  the  other  sounds  cannot  be  de- 
tected. They  are,  however,  so  irregular,  and  so  often  entirely  absent, 
that  they  can  hardly  be  looked  upon  in  any  other  light  than  as 
occasional  phenomena. 

Sounds  referred  to  Decomposition  of  the  Liguor  Amnii  and  to  sepa- 
ration of  the  Placenta. — Two  other  sounds  have  been  described  as 
being  sometimes  audible,  which  may  be  mentioned  as  matters  of 
interest,  but  which  are  of  no  diagnostic  value.  One  is  a  rustling 
sound,  said  by  Stoltz  to  be  audible  in  cases  in  which  the  foetus  is 
dead,  and  which  he  refers  to  gaseous  decomposition  of  the  liquor 
amnii:  its  existence  is.  however,  extremely  problematical.  The 
other  is  a  sound  heard  after  the  birth  of  the  child,  and  referred  by 
Caillant  to  the  separation  of  the  placental  adhesions.  He  describes 
it  as  a  series  of  rapid  short  scratching  sounds,  similar  to  those  pro- 
duced by  drawing  the  nails  across  the  seat  of  a  horse-hair  sofa.  Simp- 
son1 admits  the  existence  of  the  sound,  but  believed  that  it  is  produced 
by  the  mere  physical  crushing  of  the  placenta,  and  artificially  imitated 
it  out  of  the  body  by  forcing  the  placenta  through  an  aperture  the 
size  of  the  os  uteri. 

Relative  Value  of  the  Signs  and  Symptoms  of  Pregnancy. — It  will 
be  seen,  then,  that  although  there  are  numerous  signs  and  symptoms 
accompanying  pregnancy,  many  of  them  are  unreliable  by  them- 
selves, and  apt  to  mislead.  Those  which  may  be  confidently  de- 
pended on  are  the  pulsations  of  the  foetal  heart,  which,  however,  fail 
us  in  cases  of  dead  children ;  the  foetal  movements  when  distinctly 
made  out;  ballottement ;  the  intermittent  contractions  of  the  uterus; 
and  to  these  we  may  safely  add  the  presence  of  milk  in  the  breasts, 
provided  we  have  to  do  with  a  first  pregnancy. 

The  remainder  are  of  importance  in  leading  us  to  suspect  preg- 
nancy, and  in  corroborating  and  strengthening  other  symptoms,  but 
they  do  not,  of  themselves,  justify  a  positive  diagnosis. 

1  Selected  Obstet.  Works,  p.  151. 


148  PREGNANCY. 


CHAPTER  V. 

THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  SPURIOUS  PREG- 
NANCY. THE  DURATION  OF  PREGNANCY.  SIGNS  OF  RECENT 
DELIVERY. 

Importance  of  the  Subject. — The  differential  diagnosis  of  pregnancy 
has  of  late  years  assumed  much  importance  on  account  of  the  advance 
of  abdominal  surgery.  The  cases  are  so  numerous  in  which  even 
the  most  experienced  practitioners  have  fallen  into  error,  and  in 
which  the  abdomen  has  been  laid  open  in  ignorance  of  the  fact  that 
pregnancy  existed,  that  the  subject  becomes  one  of  the  greatest  con- 
sequence. Fortunately  it  is  less  so  from  an  obstetrical  than  from  a 
gynaecological  point  of  view,  inasmuch  as  the  converse  error,  of  mis- 
taking some  other  condition  for  pregnancy,  is  of  far  less  consequence, 
as  it  is  one  which  time  will  always  rectify.  But  even  in  this  way 
carelessness  may  lead  to  very  serious  injury  to  the  character,  if  not 
to  the  health  of  the  patient ;  and  it  will  be  well  to  refer  briefly  to 
some  of  the  conditions  most  liable  to  be  mistaken  for  pregnancy,  and 
to  the  mode  of  distinguishing  them. 

Adipose  enlargement  of  the  abdomen  may  obscure  the  diagnosis  by 
preventing  the  detection  of  the  uterus ;  and  if,  as  is  not  uncommon 
in  women  of  great  obesity,  it  is  associated  with  irregular  menstrua- 
tion, the  increased  size  of  the  abdomen  might  be  supposed  to  depend 
on  pregnancy.  The  absence  of  corroborative  signs,  such  as  ausculta- 
tory  phenomena,  mammary  changes,  and  the  hardness  of  the  cervix 
as  felt  per  vaginam,  make  it  easy  to  avoid  this  error. 

Distension  of  the  uterus  by  retained  menstrual  fluid,  or  watery 
secretion,  is  an  occurrence  of  rarity  that  could  seldom  give  rise  to 
error.  Still  it  occasionally  happens  that  the  uterus  becomes  enlarged 
in  this  way,  sometimes  reaching  even  to  the  level  of  the  umbilicus, 
and  that  the  physical  character  of  the  tumor  is  not  unlike  that  of  the 
gravid  uterus.  The  best  safeguard  against  mistakes  will  be  the 
previous  history  of  the  case,  which  will  always  be  different  from  that 
of  ordinary  pregnancy.  Retention  of  the  menses  almost  always 
occurs  from  some  physical  obstruction  to  the  exit  of  the  fluid,  such 
as  imperforate  hymen ;  or  if  it  occur  in  women  who  have  already 
menstruated,  we  may  usually  trace  a  history  of  some  cause,  such  as 
inflammation  following  an  antecedent  labor,  which  has  produced 
occlusion  of  some  part  of  the  genital  tract.  The  existence  of  a  pelvic 
tumor  in  a  girl  who  has  never  menstruated  will  of  itself  give  rise  to 
suspicion,  as  pregnancy  under  such  circumstances  is  of  extreme 
rarity.  It  will  also  be  found  that  general  symptoms  have  existed 
for  a  period  of  time  considerably  longer  than  the  supposed  duration 
of  pregnancy,  as  judged  of  by  the  size  of  the  tumor.  The  most 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  149 

characteristic  of  them  are  periodic  attacks  of  pain  due  to  the  addition, 
at  each  monthly  period,  to  the  quantity  of  retained  menstrual  fluid. 
Whenever,  from  any  of  these  reasons,  suspicion  of  the  true  character 
of  the  case  has  arisen,  a  careful  vaginal  examination  will  generally 
clear  it  up.  Tn  most  cases  the  obstruction  will  be  in  the  vagina,  and 
is  at  once  detected,  the  vaginal  canal  above  it,  as  felt  per  rectum, 
being  greatly  distended  by  fluid ;  and  we  may  also  find  the  bulging 
and  imperforate  hymen  protruding  through  the  vulva.  The  absence 
of  mammary  changes,  and  of  ballottement,  will  materially  aid  us  in 
forming  a  diagnosis. 

Congestive  Hypertrophy  of  the  Uterus. — The  engorged  and  enlarged 
uterus,  frequently  met  with  in  women  suffering  from  uterine  disease, 
might  readily  be  mistaken  for  an  early  pregnancy,  if  it  happened  to 
be  associated  with  amenorrhea.  A  little  time  would,  of  course,  soon 
clear  up  the  point,  b}7  showing  that  progressive  increase  in  size,  as 
in  pregnancy,  does  not  take  place.  This  mistake  could  only  be  made 
at  an  early  stage  of  pregnancy,  when  a  positive  diagnosis  is  never 
possible.  The  accompanying  symptoms — pain,  inability  to  walk,  and 
tenderness  of  the  uterus  on  pressure — would  further  prevent  such  an 
error. 

Ascitic  Distension  of  the  Abdomen. — Ascites,  per  se,  could  hardly  be 
mistaken  for  pregnancy ;  for  the  uniform  distension  and  evident 
fluctuation,  the  absence  of  any  definite  tumor,  the  site  of  resonance 
on  percussion  changing  in  accordance  with  alteration  of  the  position 
of  the  woman,  and  the  unchanged  cervix  and  uterus,  should  be  suffi- 
cient to  clear  up  any  doubt.  Pregnancy  may,  however,  exist  with 
ascites,  and  this  combination  may  be  difficult  to  detect,  and  might 
readily  be  mistaken  for  ovarian  disease,  associated  with  ascites.  The 
existence  of  mammary  changes,  the  presence  of  the  softened  cervix, 
ballottement,  and  auscultation-^-provided  the  sounds  were  not  masked 
by  the  surrounding  fluid — would  afford  the  best  means  of  diagnosing 
such  a  case. 

Uterine  and  Ovarian  Tumors. — One  of  the  most  frequent  sources 
of  difficulty  is  the  differential  diagnosis  of  large  abdominal  tumors, 
either  fibroid  or  ovarian,  or  of  some  enlargements  due  to  malignant 
disease  of  the  peritoneum  or  abdominal  viscera.  The  most  expe- 
rienced have  been  occasionally  deceived  under  such  circumstances. 
As  a  rule,  the  presence  of  menstruation  will  prevent  error,  as  this 
generally  continues  in  ovarian  disease,  while  in  fibroids  it  is  often 
excessive.  The  character  of  the  tumor — the  fluctuation  in  ovarian 
disease,  the  hard  nodular  masses  in  fibroid — and  the  history  of  the 
case — especially  the  length  of  time  the  tumor  has  existed — will  aid 
in  diagnosis,  while  the  absence  of  cervical  softening,  and  of  auscultatory 
phenomena  will  further  be  of  material  value  in  forming  a  conclusion. 
Some  of  the  most  difficult  cases  to  diagnose  are  those  in  which  preg- 
nancy complicates  ovarian  or  fibroid  disease.  Then  the  tumor  may 
more  or  less  completely  obscure  the  physical  signs  of  pregnancy. 
The  usual  shape  of  the  abdomen  will  generally  be  altered  consider- 
ably, and  we  may  be  able  to  distinguish  the  gravid  uterus,  separated 
from  the  ovarian  tumor  by  a  distinct  sulcus,  or  with  the  fibroid 


150  PREGNANCY. 

masses  cropping  out  from  its  surface.  Our  chief  reliance  must  then 
be  placed  in  the  alteration  of  the  cervix,  and  in  the  auscultatory 
signs  of  pregnancy. 

/Spurious  Preynancy, — .The  condition  most  likely  to  give  rise  to 
errors  is  that  very  interesting  and  peculiar  state,  known  as  spurious 
pregnancy.  In  this  most  of  the  usual  phenomena  of  pregnancy  are 
so  strangely  simulated,  that  accurate  diagnosis  is  often  far  from  easy. 
There  are  hardly  any  of  the  more  apparent  symptoms  of  pregnancy 
which  may  not  be  present  in  marked  cases  of  this  kind.  The  abdo- 
men may  become  prominent,  the  areolae  altered,  menstruation  arrested, 
and  apparent  foetal  motions  felt ;  and,  unless  suspicion  is  aroused,  and 
a  careful  physical  examination  made,  both  the  patient  and  the  prac- 
titioner may  easily  be  deceived. 

Cases  in  which  /Spurious  Pregnancy  occurs. — There  is  no  period  of 
the  child-bearing  life  in  which  spurious  pregnancy  may  not  be  met 
with ;  but  it  is  most  likely  to  occur  in  elderly  women  about  the 
climacteric  period,  when  it  is  generally  associated  with  ovarian  irrita- 
tion connected  with  the  change  of  life ;  or  in  younger  women,  who 
are  either  very  desirous  of  finding  themselves  pregnant,  or  who,  being 
unmarried,  have  subjected  themselves  to  the  chance  of  being  so.  In 
all  cases  the  mental  faculties  have  much  to  do  with  its  production, 
and  there  is  generally  either  very  marked  hysteria,  or  even  a  condi- 
tion closely  allied  to  insanity.  Spurious  pregnancy  is  by  no  means 
confined  to  the  human  race.  It  is  well  known  to  occur  in  many  of 
the  lower  animals.  Harvey  related  instances  in  bitches,  either  after 
unsuccessful  intercourse,  or  in  connection  with  their  being  in  heat, 
even  when  no  intercourse  had  occurred.  In  such  cases  the  abdomen 
swelled,  and  milk  appeared  in  the  mammae.  Similar  phenomena  are 
also  occasionally  met  with  in  the  cow.  In  these  instances,  as  in  the 
human  female,  there  is  probably  some  morbid  irritation  of  the  ova- 
rian system. 

Its  Signs  and  Symptoms. — The  physical  phenomena  are  often  very 
well  marked.  The  apparent  enlargement  is  sometimes  very  great, 
and  it  seems  to  be  produced  by  a  projection  forward  of  the  abdomi- 
nal contents  due  to  depression  of  the  diaphragm,  together  with 
rigidity  of  the  abdominal  muscles,  and  may  even  closely  simulate 
the  uterine  tumor  on  palpation.  After  the  climacteric  it  is  frequently 
associated,  as  Gooch  pointed  out,  with  an  undue  deposit  of  fat  in  the 
abdominal  walls  and  omentum,  so  that  there  may  be  even  some  dul- 
ness  on  percussion,  instead  of  resonance  of  the  intestines.  The  foetal 
movements  are  curiously  and  exactly  simulated,  either  by  involun- 
tary contractions  of  the  abdominal  walls,  or  by  the  movement  of 
flatus  in  the  intestines.  '  The  patient  also  generally  fancies  that  she 
suffers  from  the  usual  sympathetic  disorders  of  pregnancy,  and  thus 
her  account  of  her  symptoms  will  still  further  tend  to  mislead. 

Sometimes  followed  by  Spurious  Labor. — Not  only  may  the  supposed 
pregnancy  continue,  but,  at  what  would  be  the  natural  term  of  de- 
livery, all  the  phenomena  of  labor  may  supervene.  Many  authentic 
cases  are  on  record  in  which  regular  pains  came  on,  and  continued 
to  increase  in  force  and  frequency  until  the  actual  condition  was 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  151 

diagnosed.  Such  mistakes,  however,  are  only  likely  to  happen  when 
the  statements  of  the  patient  have  been  received  without  further 
inquiry.  When  once  an  accurate  examination  has  been  made,  error 
is  no  longer  possible. 

Methods  of  Diagnosis. — We  shall  generally  find  that  some  of  the 
phenomena  of  pregnancy  are  absent.  Possibly  menstruation,  more 
or  less  irregular,  may  have  continued.  Examination  per  vaginam 
will  at  once  clear  up  the  case,  by  showing  that  the  uterus  is  not 
enlarged,  and  that  the  cervix  is  unaltered.  It  may  then  be  very 
difficult  to  convince  the  patient  or  her  friends  that  her  symptoms 
have  misled  her,  and  for  this  purpose  the  inhalation  of  chloroform  is 
of  great  value.  As  consciousness  is  abolished,  the  serni- voluntary 
projection  of  the  abdominal  muscles  is  prevented,  the  large  apparent 
tumor  vanishes,  and  the  bystanders  can  be  readily  convinced  that 
none  exists.  As  the  patient  recovers,  the  tumor  again  appears. 

Duration  of  Pregnancy. — The  duration  of  pregnancy  in  the  human 
female  has  always  formed  a  fruitful  theme  for  discussion  amongst 
obstetricians.  The  reasons  which  render  the  point  difficult  of  deci- 
sion are  obvious.  As  the  large  majority  of  cases  occur  in  married 
women,  in  whom  intercourse  occurs  frequently,  there  is  no  means  of 
knowing  the  precise  period  at  which  conception  took  place.  The 
only  datum  which  exists  for  the  calculation  of  the  probable  date  of 
delivery  is  the  cessation  of  menstruation.  It  is  quite  possible,  how- 
ever, and  indeed  probable,  that  conception  occurred,  in  a  considerable 
number  of  instances,  not  immediately  after  the  last  period,  but  im- 
mediately before  the  proper  epoch  for  the  occurrence  of  the  next. 
Hence,  as  the  interval  between  the  end  of  one  menstruation  and  the 
commencement  of  the  next  averages  25  days,  an  error  to  that  extent 
is  always  possible.  Another  source  of  fallacy  is  the  fact,  which  has 
generally  been  overlooked,  that  even  a  single  coitus  does  not  fix  the 
date  of  conception,  but  only  that  of  insemination.  It  is  well  known 
that  in  many  of  the  lower  animals  the  fertilization  of  the  ovule  does 
not  take  place  until  several  days  after  copulation,  the  spermatozoa 
remaining  in  the  interval  in  a  state  of  active  vitality  within  the 
genital  tract.  It  has  been  shown  by  Marion  Sims  that  living  sper- 
matozoa exist  in  the  cervical  canal  in  the  human  female  some  days 
after  intercourse.  It  is  very  probable,  therefore,  that  in  the  human 
female,  as  in  the  lower  animals,  a  considerable,  but  unknown  interval, 
occurs  between  insemination  and  actual  impregnation,  which  may 
render  calculations  as  to  the  precise  duration  of  pregnancy  altogether 
unreliable. 

Average  Time  between  Cessation  of  Menstruation  and  Delivery. — A 
large  mass  of  statistical  observations  exist  respecting  the  average 
duration  of  gestation,  which  have  been  drawn  up  and  collated  from 
numerous  sources.  It  would  serve  no  practical  purpose  to  reprint 
the  voluminous  tables  on  this  subject  that  are  contained  in  obstetrical 
works.  They  are  based  on  two  principal  methods  of  calculation. 
First,  we  have  the  length  of  time  between  the  cessation  of  menstrua- 
tion and  delivery.  This  is  found  to  vary  very  considerably,  but  the 
largest  percentage  of  deliveries  occurs  between  the  274th  and  280th 

zGiE  or  i?tnifin=ATi-i 


152  PREGNANCY. 

day  after  the  cessation  of  menstruation,  the  average  day  being  the 
278th  ;  but,  in  individual  instances,  very  considerable  variations  both 
above  and  below  these  limits  are  found  to  exist.  Next  we  have  a 
series  of  cases,  from  various  sources,  in  which  only  one  coitus  was 
believed  to  have  taken  place.  These  are  naturally  always  open  to 
some  doubt,  but,  on  the  whole,  they  may  be  taken  as  affording  tole- 
rably fair  grounds  for  calculation.  Here,  as  in  the  other  mode  of 
calculation,  there  are  marked  variations,  the  average  length  of  time, 
as  estimated  from  a  considerable  collection  of  cases,  being  275  days 
after  the  single  intercourse.  It  may,  therefore,  be  taken  as  certain 
that  there  is  no  definite  time  which  we  can  calculate  on  as  being  the 
proper  duration  of  pregnancy,  and,  consequently,  no  method  of  esti- 
mating the  probable  date  of  delivery  on  which  we  can  absolutely 
rely. 

Methods  of  Predicting  the  probable  Date. — The  prediction  of  the 
time  at  which  the  confinement  may  be  expected  is,  however,  a  point 
of  considerable  practical  importance,  and  one  on  which  the  medical 
attendant  is  always  consulted.  Various  methods  of  making  the 
calculation  have  been  recommended.  It  has  been  customary  in  this 
country,  according  to  the  recommendation  of  Montgomery,  to  fix 
upon  ten  lunar  months,  or  280  days,  as  the  probable  period  of  gesta- 
tion, and,  as  conception  is  supposed  to  occur  shortly  after  the  cessa- 
tion of  menstruation,  to  add  this  number  of  days  to  any  day  within 
the  first  week  after  the  last  menstrual  period  as  the  most  probable 
period  of  delivery.  As,  however,  278  days  is  found  to  be  the  average 
duration  of  gestation  after  the  cessation  of  menstruation,  and  as  this 
method  makes  the  calculation  vary  from  281  to  287  days,  it  is  evi- 
dently liable  to  fix  too  late  a  date.  Naegele's  method  was  to  count 
7  days  from  the  first  appearance  of  the  last  menstrual  period,  and 
then  reckon  "backwards  three  months  as  the  probable  date.  Thus, 
if  a  patient  last  commenced  to  menstruate  on  August  10,  counting  in 
this  way  from  August  17  would  give  May  17  as  the  probable  date  of 
the  delivery. 

Matthews  Duncan  has  paid  more  attention  than  any  one  else  to  the 
prediction  of  the  date  of  delivery.  His  method  of  calculating  is 
based  on  the  fact  of  278  days  being  the  average  time  between  the 
cessation  of  menstruation  and  parturition ;  and  he  claims  to  have  had 
a  greater  average  of  success  in  his  predictions  than  on  any  other  plan. 
His  rule  is  as  follows : — "  Find  the  day  on  which  the  female  ceased 
to  menstruate,  or  the  first  clay  of  being  what  she  calls  "  well."  Take 
that  day  nine  months  forward  as  275,  unless  February  is  included, 
in  which  case  it  is  taken  as  273  days.  To  this  add  three  days  in  the 
former  case,  or  five  if  February  is  in  the  count,  to  make  up  the  278. 
This  278th  day  should  then  be  fixed  on  as  the  middle  of  the  week, 
or,  to  make  the  prediction  the  more  accurate,  of  the  fortnight  ia 
which  the  confinement  is  likely  to  occur,  by  which  means  allowance 
is  made  for  the  average  variation  of  either  excess  or  deficiency." 

Various  periodoscopes  and  tables  for  facilitating  the  calculation 
have  been  made.  The  periodoscope  of  Dr.  Tyler  Smith  (sold  by 
Messrs.  John  Smith,  52  Long  Acre)  is  very  useful  for  reference  in 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY 


the  consulting  room,  giving  at  a  glance  a  variety  of  information, 
such  as  the  probable  period  of  quickening,  the  dates  for  the  induc- 
tion of  premature  labor,  etc.  The  following  table,  prepared  by  Dr. 
Protheroe  Smith,  is  also  easily  read,  and  is  very  serviceable : — 

TABLE  FOR  CALCULATING  THE  PERIOD  OF  UTERO-GESTATIOX.' 


Nine  Calendar  Months. 

Ten  Lunar  Months. 

From 

To 

Days. 

To 

Days. 

January       1 

September  30 

273 

October        7 

280 

February     1 

October       31 

273 

November  7 

280 

March          1 

November  30 

275 

December  5 

280 

April            1 

December  31 

275 

January       5 

280 

May             1 

January       31 

276 

February     4 

280 

June             1 

February     28 

273 

March          7 

280 

July             1 

March          31 

274 

April            G 

280 

August        1 

April           30 

273 

May             7 

280 

September  1 

May             31 

273 

June             7 

280 

October       1 

June            30 

273 

July              7 

280 

November  1 

July             31 

273 

August        7 

280 

December  1 

August        31 

274 

September  6 

280 

Quickening  a  Fallacious  Guide  in  estimating  Date  of  Delivery. — 
The  date  at  which  the  quickening  has  been  perceived  is  relied  on  by 
many  practitioners,  and  still  more  by  patients,  in  calculating  the 
probable  date  of  delivery,  as  it  is  generally  supposed  to  occur  at  the 
middle  of  pregnancy.  The  great  variations,  however,  in  the  time  at 
which  this  phenomenon  is  first  perceived,  and  the  difficulty  which  is 
so  often  experienced  of  ascertaining  its  presence  with  any  certainty, 
render  it  a  very  fallacious  guide.  The  only  times  at  which  the  per- 
ception of  quickening  is  likely  to  prove  of  any  real  value  are  when 
impregnation  has  occurred  during  lactation  (when  menstruation  is 
normally  absent),  or  when  menstruation  is  so  uncertain  and  irregular 
that  the  date  of  its  last  appearance  cannot  be  ascertained.  As  quicken- 
ing is  most  commonly  felt  during  the  fourth  month,  more  frequently 
in  its  first  than  in  its  last  fortnight,  it  may  thus  afford  the  only  guide 
we  can  obtain,  and  that  an  uncertain  one,  for  predicting  the  date  of 
delivery. 

Is  Protraction  of  Gestation  Possible.? — From  a  medico-legal  point 
of  view  the  question  of  the  possible  protraction  of  pregnancy  beyond 
the  average  time,  and  of  the  limits  within  which  such  protraction 
can  be  admitted,  is  of  very  great  importance.  The  law  on  this  point 

1  The  above  obstetric  "Ready  Reckoner"  consists  of  two  columns,  one  of  calendar, 
the  other  of  lunar  months,  and  may  be  read  as  follows : — A  patient  has  ceased  to 
menstruate  on  July  1  :  her  confinement  may  be  expected  at  soonest  about  March  31 
(the  end  of  nine  calendar  months)  ;  or  at  latest  on  April  6,  (the  end  of  ten  lunar 
months).'  Another  has  ceased  to  menstruate  on  January  20  ;  her  confinement  may 
be  expected  on  September  30,  plus  20  days  (the  end  of  nine  calendar  months)  at 
soonest;  or  on  October  7,  plus  20  days  (the  end  of  ten  lunar  months)  at  latest. 
11 


154  PREGNANCY. 

varies  considerably  in  different  countries.  Thus  in  France  it  is  laid 
down  that  legitimacy  cannot  be  contested  until  300  days  have  elapsed 
from  the  death  of  the  husband,  or  the  latest  possible  opportunity  for 
sexual  intercourse.  This  limit  is  also  adopted  by  Austria,  while  in 
Prussia  it  is  fixed  at  302  days.  In  England  and  America  no  fixed 
date  is  admitted,  but  while  280  days  is  admitted  as  the  "legitimum 
tempus  pariendi,"  each  case,  in  which  legitimacy  is  questioned,  is  to 
be  decided  on  its  own  merits.  At  the  early  part  of  the  century  the 
question  was  much  discussed  by  the  leading  obstetricians  in  connec- 
tion with  the  celebrated  Gardner  peerage  case,  and  a  considerable 
difference  of  opinion  existed  among  them.  Since  that  time  many 
apparently  perfectly  reliable  cases  have  been  recorded,  in  which  the 
duration  of  gestation  was  obviously  much  beyond  the  average,  and 
in  which  all  sources  of  fallacy  were  carefully  excluded. 

Reliable  Cases  of  Protraction. — Not  to  burden  these  pages  with  a 
number  of  cases,  it  may  suffice  to  refer,  as  examples  of  protraction, 
to  four  well-known  instances  recorded  by  Simpson,1  in  which  the 
pregnancy  extended  respectively  to  336,  332,  319,  and  324  days  after 
the  cessation  of  the  last  menstrual  period.  In  these,  as  in  all  cases 
of  protracted  gestation,  there  is  the  possible  source  of  error  that  im- 
pregnation may  have  occurred  j  ust  before  the  expected  advent  of  the 
next  period.  Making  an  allowance  of  23  days  in  each  instance  for 
this,  we  even  then  have  a  number  of  days  much  above  the  average, 
viz.,  313,  309,  296,  and  301.  Numerous  instances  as  curious  may  be 
found  scattered  through  obstetric  literature.  Indeed,  the  experience 
of  most  accoucheurs  will  parallel  such  cases,  which  may  be  more 
common  than  is  generally  supposed,  inasmuch  as  they  are  only  likely 
to  attract  attention  wrhen  the  husband  has  been  separated  from  the 
wife  beyond  the  average  and  expected  duration  of  the  pregnancy. 

Protraction  common  in  the  Lower  Animals, — The  evidence  in  favor 
of  the  possible  prolongation  of  gestation  is  greatly  strengthened  by 
what  is  known  to  occur  in  the  lower  animals.  In  some  of  these,  as 
in  the  cow  and  the  mare,  the  precise  period  of  insemination  is  known 
to  a  certainty,  as  only  a  single  coitus  is  permitted.  Many  tables  of 
this  kind  have  been  constructed,  and  it  has  been  shown  that  there  is 
in  them  a  very  considerable  variation.  In  some  cases  in  the  cow  it 
has  been  found  that  delivery  took  place  45  days,  and  in  the  mare  43 
days  after  the  calculated  date.  Analogy  would  go  strongly  to  show, 
that  what  is  known  to  a  certainty  to  occur  in  the  lower  animals,  may 
also  take  place  in  the  human  female.  The  fact,  indeed,  is  now  very 
generally  admitted ;  but  we  are  still  unable  to  fix,  with  any  degree 
of  precision,  on  the  extreme  limit  to  which  protraction  is  possible. 
Some  practitioners  have  given  cases  in  which,  on  data  which  they 
believe  to  be  satisfactory,  pregnancy  has  been  extremely  protracted  ; 
thus  Meigs  and  Adler  record  instances  which  they  believed  to  have 
been  prolonged  to  over  a  year  in  one  case,  and  over  fourteen  months 
in  the  other.  These  are,  however,  so  problematical  that  little  weight 
can  be  attached  to  them.  On  the  whole  it  would  hardly  be  safe  to 

1  Obstet.  Memoirs,  p.  84. 


DIFFERENTIAL    DIAGNOSIS    OF    PREGNANCY.  155 

conclude  that  pregnancy  can  go  more  than  three  or  four  weeks 
beyond  the  average  time.  This  conclusion  is  justified  by  the  cases 
we  possess  in  which  pregnancy  followed  a  single  coitus,  the  longest 
of  which  was  295  days. 

Evidence  from  Size  of  Child.- — Dr.  Duncan1  is  inclined  to  refuse 
credence  to  every  case  of  supposed  protraction  unless  the  size  and 
weight  of  the  child  are  above  the  average,  believing  that  lengthened 
gestation  must  of  necessity  cause  increased  growth  of  the  child.  The 
point  requires  further  investigation,  and  it  cannot  be  taken  as  proved 
that  the  foetus  necessarily  must  be  large  because  it  has  been  retained 
longer  than  usual  in  utero ;  or,  even  if  this  be  admitted,  it  may  have 
been  originally  small,  and  so,  at  the  end  of  the  protracted  gestation, 
be  little  above  the  average  weight.  There  are,  however,  many  cases 
which  certainly  prove  that  a  prolonged  pregnancy  is  at  least  often 
associated  with  an  unusually  developed  foetus.  Dr.  Duncan  himself 
cites  several,  and  a  very  interesting  one  is  mentioned  by  Leishman, 
in  which  delivery  took  place  295  days  after  a  single  coitus,  the  child 
weighing  12  Ibs.  3  ozs. 

In  some  Cases  Labor  may  commence  and  be  Arrested. — It  seems 
possible  that,  in  some  cases  of  protracted  pregnancy,  labor  actually 
came  on  at  the  average  time,  but,  on  account  of  faulty  positions  of 
the  uterus,  or  other  obstructing  cause,  the  pains  were  ineffective  and 
ultimately  died  away,  not  recurring  for  a  considerable  time.  Joulin 
relates  some  instances  of  this  kind.  In  one  of  them  the  labor  was 
expected  from  the  20th  to  the  25th  of  October.  He  was  summoned 
on  the  23d,  and  found  the  pains  regular  and  active,  but  ineffective ; 
after  lasting  the  whole  of  the  24th  and  25th  they  died  away,  and 
delivery  did  not  take  place  until  November  25th,  after  the  lapse  of  a 
month.  In  this  instance  the  apparent  cause  of  difficulty  was  extreme 
anterior  obliquity  of  the  uterus.  A  precisely  similar  case  came 
under  my  own  observation.  The  lady  ceased  to  menstruate  on 
March  16,  1870.  On  December  12th,  that  is  on  the  273d  day, 
strong  labor  pains  came  on,  the  os  dilated  to  the  size  of  a  florin,  and 
the  membranes  became  tense  and  prominent  with  each  pain.  After 
lasting  all  night  they  gradually  died  away,  and  did  not  recur  until 
January  12th,  304  days  from  the  cessation  of  the  last  period.  Here 
there  was  no  assignable  cause  of  obstruction,  and  the  labor,  when  it 
did  come  on,  was  natural  and  easy. 

The  curious  fact  that,  in  both  these  cases,  as  in  others  of  the  same 
kind  that  are  recorded,  labor  came  on  exactly  a  month  after  the  pre- 
vious ineffectual  attempt  at  its  establishment,  affords,  so  far  as  it 
goes,  an  argument  in  favor  of  the  view  maintained  by  many  that 
labor  is  apt  to  come  on  at  what  would  have  been  a  menstrual  period. 

Signs  of  Recent  Delivery. — From  a  forensic  point  of  view  it  often 
becomes  of  importance  to  be  able  to  give  a  reliable  opinion  as  to  the 
fact  of  delivery  having  occurred,  and  a  few  words  may  be  here  said 
as  to  the  signs  of  recent  delivery.  Our  opinion  is  only  likely  to  be^ 
sought  in  cases  in  which  the  fact  of  delivery  is  denied,  and  in  which. 

1  Fecundity  and  Fertility,  p.  348. 


150  PREGNANCY. 

we  must,  therefore,  entirely  rely  on  the  results  of  a  physical  exami- 
nation. If  this  be  undertaken  within  the  first  fortnight  after  labor, 
a  positive  conclusion  can  be  readily  arrived  at. 

At  this  time  the  abdominal  walls  will  still  be  found  loose  and 
flaccid,  and  bearing  very  evident  marks  of  extreme  distension  in  the 
cracks  and  fissures  of  the  cutis  vera.  These  remain  permanent  for 
the  rest  of  the  patient's  life,  and  may  be  safely  assumed  to  be  signs 
of  an  antecedent  pregnancy,  provided  we  can  be  certain  that  no  other 
cause  of  extreme  abdominal  distension  has  existed,  such  as  ascites, 
or  ovarian  tumor. 

Within  the  first  few  days  after  delivery,  the  hard  round  ball 
formed  by  the  contracted  and  empty  uterus  can  easily  be  felt  by 
abdominal  palpation,  and  more  certainly  by  combined  external  and 
internal  examination.  The  process  of  involution,  however,  by  which 
the  uterus  is  reduced  to  its  normal  size,  is  so  rapid,  that  after  the  first 
week  it  can  no  longer  be  made  out  above  the  brim  of  the  pelvis.  In 
cases  in  which  an  accurate  diagnosis  is  of  importance,  the  increased 
length  of  the  uterus  can  be  ascertained  by  the  uterine  sound,  and  its 
cavity  will  measure  more  than  the  normal  2|  inches  for  at  least  a 
month  after  delivery.  It  should  not  be  forgotten  that  the  uterine 
parietes  are  now  undergoing  fatty  degeneration,  and  that  they  are 
more  than  usually  soft  and  friable,  so  that  the  sound  should  be  used 
with  great  caution,  and  only  when  a  positive  opinion  is  essential. 
The  state  of  the  cervix  and  of  the  vagina  may  afford  useful  in- 
formation. •  Immediately  after  delivery  the  cervix  hangs  loose  and 
patulous  in  the  vagina,  but  it  rapidly  contracts,  and  the  internal  os 
is  generally  entirely  closed  after  the  eighth  or  tenth  day.  The  re- 
mainder of  the  cervix  is  longer  in  returning  to  its  normal  shape  and 
consistency.  It  is  generally  permanently  altered  after  delivery,  the 
external  os  remaining  fissured  and  transverse,  instead  of  circular  with 
smooth  margins,  as  in  virgins.  The  vagina  is  at  first  lax,  swollen, 
and  dilated,  but  these  signs  rapidly  disappear  and  cannot  be  satisfac- 
torily made  out  after  the  first  few  days.  The  absence  of  the  fourchette 
may  be  recognized,  and  is  a  persistent  sign. 

The  presence  of  the  lochia  affords  a  valuable  sign  of  recent  deliv- 
ery. For  the  first  few  days  they  are  sanguineous,  and  contain  numer- 
ous blood-corpuscles,  epithelial  scales,  and  the  ddbris  of  the  decidua. 
After  the  fifth  day  they  generally  change  in  color,  and  become  pale 
and  greenish,  and  from  the  eighth  or  ninth  day  till  about  a  month 
after  delivery,  they  have  the  appearance  of  a  thick  opalescent  mucus. 
They  have,  however,  a  peculiar,  heavy,  sickening  odor,  which  should 
prevent  their  being  mistaken  for  either  menstruation  or  leucorrhceal 
discharge. 

The  appearance  of  the  breasts  will  also  aid  the  decision,  for  it  is 
impossible  for  the  patient  to  conceal  the  turgid  swollen  condition  of 
the  mammae,  with  the  darkened  areolae,  and,  above  all,  the  presence 
of  milk.  If,  on  microscopic  examination,  the  milk  is  found  to  con- 
tain colostrum  corpuscles,  the  fact  of  very  recent  delivery  is  certain. 
In  women  who  do  not  nurse  it  should  be  remembered  that  the  secre- 
tion of  milk  often  rapidly  disappears,  so  that  its  absence  cannot  be 


ABNORMAL    PREGNANCY.  157 

taken  as  a  sign  that  delivery  has  not  taken  place.  On  the  whole, 
there  should  be  no  difficulty  in  deciding  that  a  woman  has  been  de- 
livered, as  some  of  the  signs  are  persistent  for  the  rest  of  her  life ; 
but  it  is  not  so  easy,  unless  we  see  the  case  within  the  first  eight  or 
ten  days,  to  say  how  long  it  is  since  labor  took  place. 


CHAPTER  VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY,  SUPER- 
FCETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED  LABOR. 

Plural  Births  an  abnormal  variety  of  Pregnancy. — /The  occurrence 
of  more  than  one  foetus  in  utero  is  far  from  uncommon,  but  there 
are  circumstances  connected  with  it  which  justify  the  conclusion  that 
plural  births  must  not  be  classified  as  natural  forms  of  pregnancy. 
The  reasons  for  this  statement  have  been  well  collected  by  Dr. 
Arthur  Mitchell,1  who  conclusively  shows  that  not  only  is  there  a 
direct  increase  of  risk  both  to  the  mother  and  her  offspring,  but  that 
many  abnormalities,  such  as  idiocy,  imbecility,  and  bodily  deformity, 
occur  with  much  greater  frequency  in  twins  than  in  single-born 
children.  He  concludes  that  "the  whole  history  of  twin  births  is 
exceptional,  indicates  imperfect  development  and  feeble  organization 
in  the  product,  and  leads  us  to  regard  twinning  in  the  human  species 
as  a  departure  from  the  physiological  rule,  and  therefore  injurious 
to  all  concerned." 

Frequency  of  multiple  Births. — The  frequency  of  multiple  births 
varies  considerably  under  different  circumstances.  Taking  the  aver- 
age of  a  large  number  of  cases  collected  by  authors  in  various 
countries,  we  find  that  twin  pregnancies  occur  about  once  in  87 
labors;  triplets  once  in  7679.  A  certain  number  of  quadruple  preg- 
nancies, and  some  cases  of  early  abortion  in  which  there  were  five 
foetuses,  are  recorded,  so  that  there  can  be  no  doubt  of  the  possibility 
of  such  occurrences:  but  they  are  so  extremely  uncommon  that  they 
may  be  looked  upon  as  rare  exceptions,  the  relative  frequency  of 
which  .can  hardly  be  determined. 

Relative  frequency  in  different  Countries. — The  frequency  of  mul- 
tiple pregnancy  varies  remarkably  in  different  races  and  countries. 
The'foilowing  table2  will  show  this  at  a  glance: — 

1  Med.  Times  and  Gaz.,  Nov.  1862. 

2  Puech,  DCS  Naissances  Multiples. 


158 


PREGNANCY. 


RELATIVE  FKEQUEXCY  OF  MUTIPI.E  PUEGXAXCIES  ix  EUROPE. 


Countries. 

Proportion  of 
Twin  to  Single 
Births. 

Proportion  of 
Triplets. 

Proportion  of 
Quadruplets. 

England  . 
Austria 
Grand  Duchy  of  Baden 
Scotland  . 
France 
Ireland 
Mecklenburg-  Schwerin 
Norway    . 
Prussia 
Russia 
Saxony 
Switzerland 
Wurtemberg 

1 
1 

1 
1 

1 
1 
1 
1 
1 
1 
1 

116 
94 
89 
95 
99 
64 
68.9 
81.62 
89 
50.05 
79 
102 
862 

i 

6,720 

1 
1 
1 

1 
1 

1 

6,575 

1 

1 
1 

8,256 
4,995 
6,436 
5,442 
7,820 
4,054 
1,000 

2,074,306 
167,296 
183,236 

394,690 

400,000 

1 

6,464 

110,991 

It  will  be  seen  that  the  largest  proportion  of  multiple  births  occurs 
in  Russia,  and  that  the  number  of  triple  births  is  greatest  where  twin 
pregnancies  are  most  frequent.  Puech  concludes  that  the  number  of 
multiple  pregnancies  is  in  direct  proportion  to  the  general  fecundity 
of  the  inhabitants. 

Dr.  Duncan  has  deduced  some  interesting  laws,  with  regard  to  the 
production  of  twins,  from  a  large  number  of  statistical  observations;1 
especially  that  the  tendency  to  the  production  of  twins  increases  as 
the  age  of  the  woman  advances,  and  is  greater  in  each  succeeding 
pregnancy,  exception  being  made  for  the  first  pregnancy,  in  which  it 
is  greater  than  in  any  other.  Newly  married  women  appear  more 
likely  to  have  twins  the  older  they  are.  There  can  be  no  doubt  that 
there  is  often  a  strong  hereditary  tendency  in  individual  families  to 
multiple  births.  A  remarkable  instance  of  this  kind  is  recorded  by 
Mr.  Curgenven,2  in  which  a  woman  had  four  twin  pregnancies,  her 
mother  and  aunt  each  one,  and  her  grandmother  two.  Simpson 
mentions  a  case  of  quadruplets,  consisting  of  three  males  and  one 
female,  who  all  survived,  the  female  subsequently  giving  birth  to 
triplets.3 

Sex  of  Children. — In  the  largest  number  of  cases  of  twins  the 
children  are  of  opposite  sexes,  next  most  frequently  there  are  two 
females,  and  twin  males  are  the  most  uncommon.  Thus  out  of 
59,178  labors,  Simpson  calculates  that  twin  male  and  female  occurred 
once  in  199  labors,  twin  females  once  in  226,  and  twin  males  once  in 
258.  The  proportion  of  male  to  female  births  is  also  notably  less  in 
twin  than  in  single  pregnancies. 

Size  of  Foetuses. — Twins,  and  d  fortiori  triplets,  are  almost  always 
smaller  and  less  perfectly  developed  than  single  children.  Hence 

'  On  Fecundity,  Fertility,  and  Sterility,  p.  99. 

*  Obstet.  Trans,  vol.  xi.  3  Obstet.  Works,  p.  830. 


ABNORMAL    PREGXAXCY.  150 

the  chances  of  their  survival  are  much  less,  and  Clarke  calculates 
the  mortality  amongst  twin  children  as  one  out  of  thirteen.  Of 
triplets,  indeed,  it  is  comparatively  rare  that  all  survive  ;  while  in 
quadruplets,  premature  labor  and  the  death  of  the  foetuses  are  almost 
certain.  It  is  a  common  observation  that  twins  are  often  unequally 
developed  at  birth.  By  some  this  difference  is  attributed  to  one  of 
them  being  of  a  different  age  to  the  other.  It  is  probable,  however, 
that  in  most  of  these  cases  the  full  development  of  one  foetus  has  been 
interfered  with  by  pressure  of  the  other.  This  is  far  from  uncom- 
monly carried  to  the  extent  of  destroying  one  of  the  twins,  which  is 
expelled  at  term,  mummified  and  flattened  between  the  living  child 
and  the  uterine  wall.  In  other  cases  when  one  fcetus  dies  it  may  be 
expelled  without  terminating  the  pregnancy,  the  other  being  retained 
in  utero  and  born  at  term  ;  and  those  who  disbelieve  in  the  possi- 
bility of  superfcetation  explain  in  this  way  the  cases  in  which  it  is 
believed  to  have  occurred. 

Causes. — Multiple  pregnancies  depend  on  various  causes.  The 
most  common  is  probably  the  simultaneous,  or  nearly  simultaneous, 
maturation  and  rupture  of  two  Graafian  follicles,  the  ovules  becoming 
impregnated  at  or  about  the  same  time.  It  by  no  means  necessarily 
follows,  even  if  more  than  one  follicle  should  rupture  at  once,  that 
both  ovules  should  be  impregnated.  This  is  proved  by  the  occur- 
rence of  cases  in  which  there  are  two  corpora  lutea  with  only  one 
fcetus.  There  are  numerous  facts  to  prove  that  ovules  thrown  off 
within  a  short  time  of  each  other,  may  become  separately  impreg- 
nated, as  in  cases  in  which  negro  women  have  given  birth  to  twins, 
one  of  which  was  pure  negro,  the  other  half-caste. 

It  may  happen,  however,  that  a  single  Graafian  follicle  contains 
more  than  one  ovule,  as  has  actually  been  observed  before  its  rup- 
ture ;  or,  as  is  not  uncommon  in  the  egg  of  the  fowl,  an  ovule  may 
contain  a  double  germ,  each  of  which  may  give  rise  to  a  separate 
fcetus. 

Arrangement  of  the  Foetal  Membranes  and  Placentse. — The  various 
modes  in  which  twins  may  originate  explain  satisfactorily  the  varia- 
tions which  are  met  with  in  the  arrangement  of  the  fcetal  membranes, 
and  in  the  form  and  connections  of  the  placentas.  In  a  large  pro- 
portion of  cases  there  are  two  distinct  bags  of  membranes,  the 
septum  between  them  being  composed  of  four  layers,  viz.,  the 
chorion  and  amnion  of  each  ovum.  The  placentas  are  also  entirely 
separate.  Here  it  is  obvious  that  each  twin  is  developed  from  a 
distinct  ovum,  having  its  own  chorion  and  amnion.  On  arriving  in 
the  uterus  it  is  probable  that  each  ovum  becomes  fixed  independently 
in  the  mucous  membrane,  and  is  surrounded  by  its  own  decidua 
reflexa.  As  growth  advances,  the  decidua  reflexa  generally  atro- 
phies from  pressure,  as  it  is  not  usual  to  find  more  than  four  layers 
of  membrane  in  the  septum  separating  the  ova.  In  other  cases  there 
is  only  one  chorion,  within  which  are  two  distinct  amnions,  the  sep- 
tum then  consisting  of  two  layers  only.  Then  the  placentas  are 
generally  in  close  apposition,  and  become  fused  into  a  single  mass ; 
the  cords,  separately  attached  to  each  fcetus,  not  infrequently  uniting 


160  PREGNANCY. 

shortly  before  reaching  the  placental  mass,  their  vessels  anastomosing 
freely.  In  other  more  rare  instances  both  foetuses  are  contained  in 
a  common  amniotic  sac ;  but,  as  the  amnion  is  a  purely  foetal  mem- 
brane, it  is  probable  that,  when  this  arrangement  is  met  with,  the 
originally  existing  septum  between  the  amniotic  sacs  has  been 
destroyed.  In  both  these  latter  cases  the  twins  must  have  been  de- 
veloped from  a  single  ovule  containing  a  double  germ,  and  Schroeder 
states  that  they  are  then  always  of  the  same  sex.  Dr.  Brunton1  has 
started  a  precisely  opposite  theory,  and  has  tried  to  prove  that  twins 
of  the  same  sex  are  contained  m  separate  bags  of  membrane,  while 
twins  of  opposite  sexes  have  a  common  sac.  He  says  that  out  of 
twenty-five  cases  coming  under  his  observation,  in  fifteen  the 
children  contained  in  different  sacs  were  of  the  same  sex,  but  in  the 
remaining  ten,  in  which  there  was  only  one  sac,  they  were  of  opposite 
sexes.  It  is  difficult  to  believe  that  there  is  not  an  error  in  these 
observations,  since  twins  contained  in  a  single  amniotic  sac  do  not 
occur  nearly  as  often  as  ten  times  out  of  twenty-five  cases,  and  no 
distinction  is  made  between  a  common  chorion  with  two  amnions 
and  a  single  chorion  and  amnion.  The  facts  of  double  monstrosity 
also  disprove  this  view,  since  conjoined  twins  must  of  necessity  arise 
from  a  single  ovule  with  a  double  germ,  and  there  is  no  instance  on 
record  in  which  they  were  of  opposite  sexes. 

Membranes  and  Placentae  in  Triplets. — In  triplets  the  membranes 
and  placentae  may  be  all  separate,  or,  as  is  commonly  the  case,  there  is 
one  complete  bag  of  membranes,  and  a  second  having  a  common 
chorion,  with  a  double  amnion.  It  is  probable,  therefore,  that  trip- 
lets are  generally  developed  from  two  ovules,  one  of  which  contained 
a  double  germ. 

Diagnosis  of  Multiple  Pregnancy. — It  is  comparatively  seldom  that 
twin  pregnancy  can  be  diagnosed  before  the  birth  of  the  first  child, 
and  even  when  suspicion  has  arisen,  its  indications  are  very  defective. 
There  is  generally  an  unusual  size  and  an  irregularity  of  shape  of 
the  uterus,  sometimes  even  a  distinct  depression  or  sulcus  between 
the  two  foetuses.  When  such  a  sulcus  exists  it  may  be  possible  to 
make  out  parts  of  each  foetus  by  palpation  on  either  side  of  the 
uterus.  The  only  sign,  however,  on  which  the  least  reliance  can  be 
placed  is  the  detection  of  two  foetal  hearts.  If  two  distinct  pulsations 
are  heard  at  different  parts  of  the  uterus;  if,  on  carrying  the  stetho- 
scope from  one  point  to  another,  there  is  an  interspace  where  the 
pulsations  are  no  longer  audible,  or  when  they  become  feeble,  and 
again  increase  in  clearness  as  the  second  point  is  reached  ;  and,  above 
all,  if  we  are  able  to  make  out  a  difference  in  frequency  between 
them,  the  diagnosis  is  tolerably  safe.  It  must  be  remembered,  how- 
ever, that  the  sounds  of  a  single  heart  may  be  heard  over  a  larger 
space  than  usual,  and  hence  a  possible  source  of  error.  Twin  preg- 
nancy, moreover,  may  readily  exist  without  the  most  careful  auscul- 
tation enabling  us  to  detect  a  double  pulsation,  especially  if  one  child 
lie  in  the  dorso-posterior  position,  when  the  body  of  the  other  may 

1  Obst.  Trans,  vol.  x. 


ABNORMAL    PREGNANCY.  161 

prevent  the  transmission  of  its  heart's  beat.  The  so-called  placental 
souffle  is  generally  too  diffuse  and  irregular  to  be  of  any  use  in 
diagnosis,  even  when  it  is  distinctly  heard  at  separate  parts  of  the 
uterus. 

Superfcetation  and  Superfecundation. — Closely  connected  Avith  the 
subject  of  multiple  pregnancies  are  the  conditions  known  as  super- 
fecundation  and  super/citation,  regarding  which  there  has  been  much 
controversy  and  difference  of  opinion. 

By  the  former  is  meant  the  fecundation,  at  or  near  the  same  period 
of  time,  of  two  separate  ovules  before  the  decidua  lining  the  uterus 
has  been  formed,  which  by  many  is  supposed  to  form  an  insuperable 
obstacle  to  subsequent  impregnation.  The  possibility  of  this  occur- 
rence has  been  incontestably  proved  by  the  class  of  cases  already 
referred  to,  in  which  the  same  woman  has  given  birth  to  twins  bear- 
ing evident  traces  of  being  the  offspring  of  fathers  of  different  races. 

By  superfoe.tation  is  meant  the  impregnation  of  a  second  ovule, 
when  the  uterus  already  contains  an  ovum  which  has  arrived  at  a 
considerable  degree  of  development.  The  cases  which  are  supposed 
to  prove  the  possibility  of  this  occurrence  are  very  numerous.  They 
are  those  in  which  a  woman  is  delivered  simultaneously  of  foetuses 
of  very  different  ages,  one  bearing  ail  the  marks  of  having  arrived 
at  term,  the  other  of  prematurity ;  or  of  those  in  which  a  woman  is 
delivered  of  an  apparently  mature  child,  and,  after  the  lapse  of  a  few 
months,  of  another  equally  mature.  The  possibility  of  superfoetation 
is  strongly  denied  by  many  practitioners  of  eminence,  and  explana- 
tions are  given,  which  doubtless  seem  to  account  satisfactorily  for  a 
large  proportion  of  the  supposed  examples.  In  the  former  class  of 
cases  it  is  supposed,  with  much  probability,  that  there  is  an  ordinary 
twin  pregnancy,  the  development  of  one  foetus  being  retarded  by  the 
presence  in  utero  of  another.  That  this  is  not  an  uncommon  occur- 
rence is  certain,  and  the  fact  has  already  been  alluded  to  in  treating 
of  twin  pregnancy.  In  cases  of  the  latter  kind  it  is  possible  that 
some  of  them  may  be  due  to  separate  impregnation  in  a  bilobed 
uterus,  the  contents  of  one  division  being  thrown  off  a  considerable 
time  before  those  of  the  other.  Numerous  authentic  examples  of 
this  occurrence  are  recorded,  but  by  far  the  most  remarkable  is  that 
related  by  Dr.  Eoss,  of  Brighton,  which  has  been  already  referred  to 
(p.  58).  In  this  case  the  patient  had  previously  given  birth  to  many 
children  without  any  suspicion  of  her  abnormal  formation  having 
arisen,  and,  had  it  not  been  detected  by  Dr.  Eoss,  the  case  might 
fairly  enough  have  been  claimed  as  an  indubitable  example  of  super- 
foetation. 

Making  every  allowance  for  these  explanations,  there  remain  a 
considerable  number  of  cases  which  it  is  very  difficult  to  account  for, 
except  on  the  supposition  that  the  second  child  has  been  conceived  a 
considerable  time  after  the  first.  Those  interested  in  the  subject 
will  find  a  large  number  of  examples  collected  in  a  valuable  paper 
by  Dr.  Bonnar,  of  Cupar.1  He  has  adopted  the  ingenious  plan  of 

1  Edin.  Med.  Jour.,  1864-65. 


1G2  PREGNANCY. 

consulting  the  records  of  the  British  peerage,  where  the  exact  date 
of  the  birth  of  successive  children  of  peers  is  given,  without,  of 
course,  any  reasonable  possibilit^y  of  error,  and  he  has  collected 
numerous  examples  of  births  rapidly  succeeding  each  other,  which 
are  apparently  inexplicable  on  any  other  theory.  In  one  case  he 
cites,  a  child  was  born  September  12,  1849,  and  the  mother  gave 
birth  to  another  on  January  24,  1850,  after  an  interval  of  only  127 
days.  Subtracting  from  that  14  days,  which  Dr.  Bonnar  assumes  to 
be  the  earliest  possible  period  at  which  a  fresh  impregnation  can 
occur  after  delivery,  we  reduce  the  gestation  to  113  days,  that  is  to 
less  than  four  calendar  months.  As  both  these  children  survived, 
the  second  child  could  not  possibly  have  been  the  result  of  a  fresh 
impregnation  after  the  birth  of  the  first ;  nor  could  the  first  child 
have  been  a  twin  prematurely  delivered,  for  if  so  it  must  have  only 
reached  rather  more  than  the  fifth  month,  at  which  time  its  survival 
would  have  been  impossible. 

Besides  the  numerous  examples  of  cases  of  this  kind  recorded  in 
most  obstetric  works,  there  are  one  or  two  of  miscarriage  in  the 
early  months,  in  which,  in  addition  to  a  foetus  of  four  or  five  months' 
growth,  a  perfectly  fresh  ovum  of  not  more  than  a  month's  develop- 
ment was  thrown  off'.  One  such  case  was  shown  at  the  Obstetrical 
Society  in  1862,  which  was  reported  on  by  Drs.  Harley  and  Tanner, 
who  stated  that  in  their  opinion  it  was  an  example  of  superfoetation. 
A  still  more  conclusive  case  is  recorded  by  Tyler  Smith.1  "A  young 
married  woman,  pregnant  for  the  first  time,  miscarried  at  the  end  of 
the  fifth  month,  and  some  hours  afterwards  a  small  clot  was  dis- 
charged, inclosing  a  perfectly  healthy  ovum  of  about  one  month. 
There  were  no  signs  of  a  double  uterus  in  this  case.  The  patient  had 
menstruated  regularly  during  the  time  she  had  been  pregnant."  This 
case  is  of  special  interest  from  the  fact  of  the  patient  having  men- 
struated during  pregnancy — a  circumstance  only  explicable  on  the 
same  anatomical  grounds  which  render  superfoetation  possible.  So 
far  as  I  know,  it  is  the  only  instance  in  which  the  coincidence  of 
superfoetation  and  menstruation  during  early  pregnancy  has  been 
observed. 

Objections. — The  objections  to  the  possibility  of  superfoetation  are 
based  on  the  assumptions  that  the  decidua  so  completely  fills  up  the 
uterine  cavity  that  the  passage  of  the  spermatozoa  is  impossible ; 
that  their  passage  is  prevented  by  the  mucous  plug  which  blocks  up 
the  cervix ;  and  that  when  impregnation  has  taken  place  ovulation 
is  suspended.  It  is,  however,  certain  that  none  of  these  are  insupera- 
ble obstacles  to  a  second  impregnation.  The  first  was  originally 
based  on  the  older  and  erroneous  view  which  considered  the  decidua 
to  be  an  exudation  lining  the  entire  uterine  cavity,  and  sealing  up 
the  mouths  of  the  Fallopian  tubes  and  the  aperture  of  the  internal  os 
uteri.  The  decidua  reflexa,  however,  does  not  come  into  apposition 
with  the  decidua  vera  until  about  the  eighth  week  of  pregnancy,  and, 
therefore,  until  that  time  there  is  a  free  space  between  the  two  mem- 

1  Manual  of  Obstetrics,  p.  112. 


ABNORMAL    PREGNANCY.  163 

branes  through  which  the  spermatozoa  might  pass  to  the  open 
mouths  of  the  Fallopian  tube,  and  in  which  a  newly-impregnated 
ovule  might  graft  itself.  A  reference  to  the  accompanying  figure  of 
,  a  pregnancy  in  the  third  month,  copied  from  Coste's  work,  will 
readily  show  that,  as  far  as  the  decidua  is  concerned,  there  is  no 
mechanical  obstacle  to  the  descent  and  lodgment  of  another  impreg- 
nated ovule  (Fig.  75).  Then,  as  regards  the  plug  of  mucus,  it  is 

FIG.  75. 


Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  Reflexa  during  the  early 
months  of  Pregnancy.     (After  Coste.) 

pretty  certain  that  this  is  in  no  way  different  from  the  mucus  filling 
the  cervix  in  the  non-pregnant  state,  which  offers  no  obstacle  at  all 
to  the  passage  of  the  spermatozoa.  Lastly,  respecting  the  cessation 
of  ovulation  during  pregnancy,  this,  no  doubt,  is  the  rule,  and  proba- 
bly satisfactorily  explains  the  rarity  of  superfcetation.  There  are, 
however,  a  sufficient  number  of  authenticated  cases  of  menstruation 
during  pregnancy  to  prove  that  ovulation  is  not  always  absolutely 
in  abeyance ;  and,  as  long  as  it  occurs,  there  is  unquestionably  no 
positive  mechanical  obstruction,  at  least  in  the  early  months  of  preg- 
nancy, in  the  way  of  the  impregnation  and  lodgment  of  the  ovules 
that  are  thrown  off.  The  reasonable  conclusion,  therefore,  seems  to 
be  that,  although  a  large  majority  of  the  supposed  cases  are  explica- 
ble in  other  ways,  it  cannot  be  admitted  that  superfcetation  is  either 
physiologically  or  mechanically  impossible. 

Extra-uterine  Prey-nancy. — The  most  important  of  the  abnormal 
varieties  of  pregnancy,  if  we  consider  the  serious  and  very  generally 
fatal  results  attending  it,  is  the  so-called  extra-uterine fcetation,  which 
consists  in  the  arrest  and  development  of  the  ovum  outside  the  cavity 


164  PREGNANCY. 

of  the  uterus.  Of  late  years  this  subject  has  received  much  well- 
merited  attention,  which,  it  is  to  be  hoped,  may  lead  to  the  establish- 
ment of  some  definite  rules  for  the  management  of  this  most  anxious 
and  dangerous  class  of  cases. 

Site  of  Extra-uterine  Pregnancy. — The  ovum  may  be  arrested  and 
developed  in  various  situations  on  its  way  to  the  uterus,  most  com- 
monly in  some  part  of  the  Fallopian  tube,  or  it  may  be  in  the  cavity 
of  the  abdomen,  or  even  quite  beyond  it,  as  in  a  few  rare  cases  in 
which  the  ovum  has  found  its  way  into  a  hernial  sac. 

Classification. — Extra-uterine  gestation  may  be  subdivided  into  the 
following  classes :  1st,  and  most  common  of  all,  tubal  gestation,  and 
as  varieties  of  this,  although  by  some  made  into  distinct  classes,  (a) 
interstitial  and  (ft)  tubo- ovarian  gestation.  In  the  former  of  these 
subdivisions  the  ovum  is  arrested  in  the  part  of  the  Fallopian  tube 
that  is  situated  in  the  substance  of  the  uterine  parietes  ;  in  the  latter, 
at  or  near  the  fimbriated  extremity  of  the  tube — so  that  part  of  its 
cyst  is  formed  by  the  tube  and  part  by  the  ovary.  2d.  Abdominal 
gestation,  in  which  an  ovum,  instead  of  finding  its  way  into  the  tube, 
falls  into  the  peritoneal  cavity  and  there  becomes  attached  and  de- 
veloped ;  or  the  so-called  secondary  abdominal  gestation,  in  which  an 
extra-uterine  pregnancy,  originally  tubal,  becomes  ventral,  through 
rupture  of  its  cyst  and  escape  of  its  contents  into  the  abdominal  cavity. 
3d.  Ovarian  gestation,  the  existence  of  which  is  denied  by  many 
writers  of  eminence,  such  as  Velpeau  and  Arthur  Farre,  while  it  is 
maintained  by  others  of  equal  celebrity,  such  as  Kiwisch,  Coste,  and 
Hecker.  It  must  be  admitted  that  it  is  extremely  difficult  to  under- 
stand how  an  ovarian  pregnancy,  in  the  strict  sense  of  the  word,  can 
occur,  for  it  implies  that  the  ovule  has  become  impregnated  before 
the  laceration  of  the  Graafian  follicle,  through  the  coats  of  which  the 
spermatozoa  must  have  passed.  Coste,  indeed,  believes  that  this 
frequently  occurs ;  but,  while  spermatozoa  have  been  detected  on  the 
surface  of  the  ovary,  their  penetration  into  the  Graafian  follicle  has 
never  been  demonstrated.  Farre  has  also  clearly  shown  that  in  many 
cases  of  supposed  ovarian  pregnancy  the  surrounding  structures  were 
so  altered  that  it  was  impossible  to  trace  their  exact  origin,  and  to 
say,  to  a  certainty,  that  the  foetus  was  really  within  the  substance  of 
the  ovary.  Kiwisch  gives  a  reasonable  explanation  of  these  cases 
by  supposing  that  sometimes  the  Graafian  follicle  may  rupture,  but 
that  the  ovule  may  remain  within  it  without  being  discharged. 
Through  the  rent  in  the  walls  of  the  follicle  the  spermatozoa  may 
reach  and  impregnate  the  ovule,  which  may  develop  in  the  situation 
in  which  it  has  been  detained.  While,  therefore,  it  is  impossible,  in 
the  face  of  many  instances  recorded  by  reliable  authorities,  to  deny 
the  existence  of  ovarian  pregnancy,  it  must  be  considered  to  be  a 
very  rare  and  exceptional  variety,  which,  as  far  as  treatment  and 
results  are  concerned,  does  not  differ  from  tubal  gestation.  4th. 
There  are  two  rare  varieties  in  which  an  ovum  is  developed  either 
in  the  supplementary  horn  of  a  bi-lobed  uterus,  or  in  a  hernial  sac. 

For  the  sake  of  clearness,  we  may  place  these  varieties  of  extra- 
uterine  gestation  in  the  following  tabular  form  : — 


ABNORMAL    PREGNANCY.  105 

1st.  Tulal— 

(a)  Interstitial,  (b)  Tubo-ovarian. 

2d.  Abdominal — • 

(a)  Primary,  (b)  Secondary. 

3d.  Ovarian. 

4th.  In  bi-lobed  uterus,  hernial,  etc. 

Causes. — The  etiology  of  extra-uterine  foetation  in  any  individual 
case  must  necessarily  be  almost  always  obscure.  Broadly  speaking, 
it  may  be  said  that  extra-uterine  foetation  may  be  produced  by  any 
condition  which  prevents,  or  renders  difficult,  the  passage  of  the 
ovule  to  the  uterus,  while  it  does  not  prevent  the  access  of  the 
spermatozoa  to  the  ovule.  Thus  inflammatory  thickening  of  the 
coats  of  the  Fallopian  tubes  by  lessening  their  calibre,  but  not  suffi- 
ciently so  to  prevent  the  passage  of  the  spermatozoa,  may  interfere 
with  the  movements  of  the  tube  which  propel  the  ovurn  forward,  and 
so  cause  its  arrest.  A  similar  effect  may  be  produced  by  various 
morbid  conditions,  such  as  inflammatory  adhesions,  from  old-stand- 
ing peritonitis,  pressing  on  the  tube ;  obstruction  of  its  calibre  by 
inspissated  mucus  or  small  polypoid  growths ;  the  pressure  of  uterine 
or  other  tumors,  and  the  like.  The  fact  that  extra-uterine  preg- 
nancies occur  most  frequently  in  multipart,  and  comparatively  rarely 
in  women  under  thirty  years  of  age,  tends  to  show  that  these  con- 
ditions, which  are  clearly  more  likely  to  be  met  with  in  such  women 
than  in  young  primiparae,  have  .considerable  influence  in  its  causation. 
A  curiously  large  proportion  of  cases  occur  in  women  who  have 
either  been  previously  altogether  sterile,  or  in  whom  a  long  interval 
of  time  has  elapsed  since  their  last  pregnancy.  The  disturbing 
effects  of  fright,  either  during  coition  or  a  few  days  afterwards,  have 
been  insisted  on  by  many  authors  as  a  possible  cause.  Numerous 
cases  of  this  kind  are  recorded ;  and,  although  the  influence  of 
emotion  in  the  production  of  this  condition  is  not  susceptible  of  proof, 
it  is  not  difficult  to  imagine  that  spasms  of  the  Fallopian  tubes  might 
be  produced  in  this  way,  which  would  either  interfere  with  the 
passage  of  the  ovum,  or  direct  it  into  the  abdominal  cavity.  The  oc- 
currence of  abdominal  pregnancy  is  probably  less  difficult  to  account 
for  if  we  admit,  with  Coste,  that  the  ovule  becomes  impregnated  on  the 
surface  of  the  ovary  itself,  for  there  must  be  very  many  conditions 
which  prevent  the  proper  adaptation  of  the  firnbriated  extremity  of 
the  tube  to  the  surface  of  the  ovary,  and  failing  this,  the  ovum  must 
of  necessity  drop  into  the  abdominal  cavity.  Kiwisch  has  pointed  out 
that  this  is  particularly  apt  to  occur  when  the  Graafian  follicle  de- 
velops on  the  posterior  surface  of  the  ovary ;  and,  indeed,  it  is  proba- 
ble that  it  may  be  of  common  occurrence,  and  that  the  comparative 
rarity  of  abdominal  pregnancy  is  due  to  the  difficulty  with  which  the 
impregnated  ovule  engrafts  itself  on  the  surrounding  viscera.  Im- 
pregnation may  actually  occur  in  the  abdominal  cavity  itself,  of  which 
Keller1  relates  a  remarkable  instance.  In  this  case  Koeberle"  had  re- 
moved the  body  of  the  uterus  and  part  of  the  the  cervix,  leaving  the 

1  Des  Grossenes  Extra^-uterines,  Paris,  1872. 


106  PREGNANCY. 

ovaries.  In  the  portion  of  the  cervix  that  remained  there  was  a  fistu- 
lous  aperture  opening  into  the  abdominal  cavity,  through  which  semen 
passed  and  produced  an  abdominal  gestation.  Several  curious  cases 
are  also  recorded,  which  have  given  rise  to  a  good  deal  of  discussion,  in 
which  a  tubal  pregnancy  existed  while  the  corpus  luteum  was  on  the 
opposite  side  (Fig.  76).  The  most  probable  explanation,  however,  is 

FIG.  7G. 


Tubal  Pregnancy,  with  the  Corpus  Luteum  in  the  Ovary  of  the  opposite  side.     The  Decidua  is 
represented  in  the  process  of  detachment  from  the  Uterine  Cavity. 

that  the  firnbriated  extremity  of  the  tube  in  which  the  ovum  was  found 
had  twisted  across  the  abdominal  cavity  and  grasped  the  opposite 
ovary,  in  this  way,  perhaps,  producing  a  flexion  which  impeded  the 
progress  of  the  ovum  it  had  received  into  its  canal.  Tyler  Smith 
suggested  that  such  cases  might  be  explained  by  supposing  that  the 
ovum,  after  reaching  the  uterus,  failed  to  graft  itself  in  the  mucous 
membrane,  but  found  its  way  into  the  opposite  Fallopian  tube. 
Kussrnaul1  thinks  that  such  a  passage  of  the  ovum  across  the  uterine 
cavity  may  be  caused  by  muscular  contraction  of  the  uterus,  occurring 
shortly  after  conception,  squeezing  the  yet  free  ovum  upwards 
towards  the  opening  of  the  opposite  tube,  and  possibly  into  the  tube 
itself. 

The  history  and  progress  of  cases  of  extra -uterine  pregnancy  are 
materially  different  according  to  their  site,  and,  for  practical  pur- 
poses, we  may  consider  them  as  forming  two  great  classes :  the  tubal 
(with  its  varieties),  and  the  abdominal. 

Tubal  Pregnancies. — When  the  ovum  is  arrested  in  any  part  of  the 
Fallopian  tube  the  chorion  soon  commences  to  develop  villi,  just  as 
in  ordinary  pregnancy,  which  engraft  themselves  into  the  mucous 
lining  of  the  tube,  and  fix  the  ovum  in  its  new  position.  The 
mucous  membrane  becomes  hypertrophied,  much  in  the  same  way  as 
that  of  the  uterus  under  similar  circumstances;  so  that  it  becomes 
developed  into  a  sort  of  pseudo-decidua.  Inasmuch,  however,  as  the 
mucous  coat  of  the  tubes  is  not  furnished  with  tubular  glands,  a  true 
decidua  can  scarcely  be  said  to  exist,  nor  is  there  any  growth  of 

1  Mon.  f.  Geburt,  Oct.  1862. 


ABNORMAL    PREGNANCY.  luT 

membrane  around  the  ovum  analogous  to  the  decidua  reflexa.  The 
ovum  is,  therefore,  comparatively  speaking,  loosely  attached  to  its 
abnormal  situation,  and  hence  hemorrhage  from  laceration  of  the 
chorion  villi  can  very  readily  take  place. 

It  is  seldom  that  any  development  of  the  chorion  villi  into  distinct 
placental  structure  is  observed ;  this  is  probably  owing  to  the  fact, 
that  laceration  and  death  generally  occur  before  the  period  at  which 
the  placenta  is  normally  formed.  The  muscular  coat  of  the  tube 
soon  becomes  hypertrophied,  and,  as  the  size  of  the  ovum  increases, 
the  fibres  are  separated  from  each  other,  so  that  the  ovum  protrudes 
at  certain  points  through  them,  and  at  these  it  is  only  covered  by  the 
stretched  and  attenuated  mucous  and  peritoneal  coats  of  the  tube. 
At  this  time  the  tubal  pregnancy  forms  a  smooth  oval  tumor,  which. 
as  a  rule,  has  not  formed  any  adhesions  to  the  surrounding  structures 


Tubal  Pregnancy.     (From  a  Specimen  in  the  Museum  of  King's  College.) 

(Fig.  77).  The  part  of  the  tube  unoccupied  by  the  ovum  may  be 
found  unaltered,  and  permeable  in  both  directions;  or,  more  fre- 
quently, it  becomes  so  stretched  and  altered  that  its  canal  cannot  be 
detected.  Most  frequently  it  is  that  part  of  the  tube  nearest  the 
uterus  which  cannot  be  made  out.  The  condition  of  the  uterus  in 
this,  as  in  other  forms  of  extra-uterine  pregnancy,  has  been  the  sub- 
ject of  considerable  discussion.  It  is  now  universally  admitted  that 
the  uterus  undergoes  a  certain  amount  of  sympathetic  engorgement, 
the  cervix  becomes  softened,  as  in  natural  pregnancy,  and  the 
mucous  membrane  develops  into  a  true  decidua.  In  many  cases  the 
decidua  is  found  on  post-mortem  examination,  in  others  it  is  not ; 
and  hence  the  doubts  that  some  have  expressed  as  to  its  existence. 


168  PREGNANCY. 

The  most  reasonable  explanation  of  its  absence  is  that  given  by 
Duguet,1  who  has  shown  that  it  is  far  from  uncommon  for  the  uterine 
decidua  to  be  thrown  off  en  masse  during  the  hemorrhagic  dis- 
charges which  so  frequently  precede  the  fatal  issue  of  extra- uterine 
gestation. 

Interstitial  and  False  Ovarian  Pregnancy. — When  the  ovum  is 
arrested  in  that  portion  of  the  tube  passing  through  the  uterus,  in 
so-called  interstitial  pregnancy,  the  muscular  fibres  of  the  uterus 
become  stretched  and  distended,  and  form  the  outer  covering  of  the 
ovum.  When,  on  the  other  hand,  the  site  of  arrest  is  in  the  fimbri- 
ated  extremity  of  the  tube,  the  containing  cysts  is  formed  partly  of 
the  fimbrise  of  the  tube,  partly  of  ovarian  tissue ;  hence  it  is  much 
more  distensible,  and  the  pregnancy  may  continue  without  laceration 
to  a  more  advanced  period,  or  even  to  term,  so  that  when  the  ovum 
is  placed  in  this  situation,  the  case  much  more  nearly  resembles  one 
of  abdominal  pregnancy. 

Period  at  which  Rupture  Occurs. — The  termination  of  tubal  preg- 
nancy, in  the  immense  majority  of  cases,  is  death,  produced  by  lace- 
ration giving  rise  either  to  internal  hemorrhage,  or  to  subsequent 
intense  peritonitis.  Rupture  usually  occurs  at  an  early  period  of 
pregnancy,  most  generally  from  the  fourth  to  the  twelfth  week,  rarely 
later.  However,  a  few  instances  are  recorded  in  which  it  did  not 
take  place  until  the  fourth  or  fifth  month,  and  Saxtorph  and  Spiegel- 
berg  have  recorded  apparently  authentic  cases  in  which  the  preg- 
nancy advanced  to  term  without  laceration.  It  is  generally  effected 
by  distension  of  the  tube,  which  at  last  yields  at  the  point  which  is 
most  stretched ;  and  sometimes  it  seems  to  be  hastened  or  deter- 
mined by  accidental  circumstances,  such  as  a  blow  or  fall,  or  the 
excitement  of  sexual  intercourse. 

Symptoms  of  Rupture. — The  symptoms  accompanying  rupture  are 
those  of  intense  collapse,  often  associated  with  severe  abdominal 
pain,  produced  by  the  laceration  of  the  cyst.  The  patient  will  be 
found  deadly  pale,  with  a  small,  thready,  and  almost  imperceptible 
pulse,  perhaps  vomiting,  but  with  mental  faculties  clear.  If  the 
hemorrhage  be  considerable,  she  may  die  without  any  attempt  at  re- 
action. Sometimes,  however — and  this  generally  occurs  in  cases  in 
which  the  tube  tears,  the  ovum  remaining  intact — the  hemorrhage 
may  cease  on  account  of  the  ovum  protruding  through  the  aperture, 
and  acting  as  a  plug.  The  patient  may  then  imperfectly  rally,  to  be 
again  prostrated  ~by  a  second  escape  of  blood,  which  proves  fatal. 
If  the  loss  of  blood  is  not  of  itself  sufficient  to  cause  death  from 
shock  and  anosmia,  the  fatal  issue  is  generally  only  postponed,  for  the 
effused  blood  soon  sets  up  a  violent  general  peritonitis,  which  rapidly 
carries  off  the  patient.  If  she  should  survive  the  second  danger,  the 
case  is  transformed  into  one  of  abdominal  pregnancy,  the  foetus 
becoming  surrounded  by  a  capsule  produced  by  inflammatory  exuda- 
tion (Fig.  78).  The  case  is  then  subject  to  the  rules  of  treatment 

1   Annales  de  Gynecologic,  May,  1874. 


ABNORMAL    PREGNANCY. 


169 


presently  to  be   discussed  when  considering  that  variety  of  extra- 
uterine  gestation. 

FIG.  78. 


\ 


Extra-uterine  Pregnancy  at  term  of  the  Tubo-Ovarian  variety.    (After  a  Case  of  Dr.  A.  Sibley 

Campbell's.) 

Diagnosis. — The  possibility  of  diagnosing  tubal  gestation  before- 
rupture  occurs  is  a  question  of  great  and  increasing  interest,  from  the 
fact  that,  could  its  existence  be  ascertained,  we  might  very  fairly 
hope  to  avert  the  almost  certainly  fatal  issue  which  is  awaiting  the 
patient.  Unfortunately,  the  symptoms  of  tubal  pregnancy  are  always 
obscure,  and  too  often  death  occurs  without  the  slightest  suspicion  as 
to  the  nature  of  the  case  having  arisen.  In  the  first  place,,  it  is  to  be 
observed  that  all  the  usual  sympathetic  disturbances  of  pregnancy 
exist :  the  breasts  enlarge,  the  areolas  darken,  and  morning  sickness 
is  present.  There  is  also  an  arrest  of  menstruation ;  but,  after  the 
absence  of  one  or  more  periods,  there  is  often  an  irregular  hemor- 
rhagic  discharge.  This  is  an  important  symptom,  this  value  of 
which  in  indicating  the  existence  of  tubal  pregnancy  has  of  late  years 
been  much  dwelt  upon  by  various  authors,  both  in  this  country  and 
abroad.  Barnes  attributes  it  to  partial  detachment  of  the  chorion: 
villi,  produced  by  the  ovum  growing  out  of  proportion  to  the  tube 
in  which  it  is  contained.  Whether  this  is  the  correct  explanation  or 
not,  it  is  a  fact  that  irregular  hemorrhage  very  generally  precedes 
12 


170  PREGNANCY. 

the  laceration  for  several  days  or  more.  Accompanying  this  hemor- 
rhage there  is  almost  always  more  or  less  abdominal  pain,  produced 
by  the  stretching  of  the  tissues  in  which  the  ovum  is  placed,  and  this 
is  sometimes  described  as  being  of  a  very  intense  and  crampy  char- 
acter. If,  then,  we  meet  with  a  case  in  which  the  symptoms  of  early 
pregnancy  exist,  in  which  there  are  irregular  losses  of  blood,  possibly 
discharge  of  membranous  shreds,  and  abdominal  pain,  a  careful  ex- 
amination should  be  insisted  on,  and  then  the  true  nature  of  the  case 
may  possibly  be  ascertained.  Should  extra-uterine  foetation  exist, 
we  should  expect  to  find  the  uterus  somewhat  enlarged,  and  the  cer- 
vix softened,  as  in  early  pregnancy,  but  both  these  changes  are  doubt- 
less generally  less  marked  than  in  normal  pregnancy.  This  fact  of 
itself  however,  is  of  little  diagnostic  value,  for  slight  difference  of 
this  kind  must  always  be  too  indefinite  to  justify  a  positive  opinion. 

Presence  of  a  Peri-uterine  Tumor. — The  existence  of  a  peri-uterine 
tumor,  rounded  or  oval  in  outline,  and  producing  more  or  less  dis- 
placement of  the  uterus,  in  the  direction  opposite  to  that  in  which 
the  tumor  is  situated,  may  point  to  the  existence  of  tubular  foetation. 
By  bimanual  examination,  one  hand  depressing  the  abdominal  Avail, 
while  the  examining  finger  of  the  other  acts  in  concert  with  it  either 
through  the  vagina  or  rectum,  the  size  and  relations  of  the  growth 
may  be  made  out.  There  are  various  conditions,  which  give  rise  to 
very  similar  physical  signs,  such  as  small  ovarian  or  fibroid  growths, 
or  the  effusion  of  blood  around  the  uterus ;  and  the  differential  diag- 
nosis must  always  be  very  difficult,  and  often  impossible.  A  curious 
example  of  the  difficulties  of  diagnosis  is  recorded  by  Joulin,  in  which 
Huguier,  and  six  or  seven  of  the  most  skilled  obstetricians  of  Paris, 
agreed  on  the  existence  of  extra-uterine  pregnancy,  and  had,  in  con- 
sultation, sanctioned  an  operation,  when  the  case  terminated  by 
abortion,  and  proved  to  be  a  natural  pregnancy.  The  use  of  the 
uterine  sound,  which  might  aid  in  clearing  up  the  case,  is  necessarily 
contra-indicated  unless  uterine  gestation  is  certainly  disproved. 
Hence  it  must  be  admitted  that  positive  diagnosis  must  almost  always 
be  very  difficult.  So  that  the  most  we  can  say  is,  that  when  the  gen- 
eral signs  of  early  pregnancy  are  present,  associated  with  the  other 
symptoms  and  signs  alluded  to,  the  suspicion  of  tubal  pregnancy 
may  be  sufficiently  strong  to  justify  us  in  taking  such  action  as  may 
possibly  spare  the  patient  the  necessarily  fatal  consequence  of  rupture. 

Treatment. — If  the  diagnosis  were  quite  certain,  the  removal  of 
the  entire  Fallopian  tube  and  its  contents  by  abdominal  section 
would  be  quite  justifiable,  and  probably  would  neither  be  more 
difficult,  nor  more  dangerous,  than  ovariotomy;  for,  at  this  stage  of 
extra-uterine  fcetatiou,  there  are  no  adhesions  to  complicate  the 
operation.  As  yet,  however,  the  uncertainty  of  the  diagnosis  has 
prevented  the  adoption  of  the  practice. 

[In  1816,  Dr.  John  King,1  of  Edisto  Island,  South  Carolina,  ope- 
rated upon  a  case  of  extra-uterine  pregnancy  by  the  vaginal  section, 
and  saved  both  mother  and  child.  The  placenta  was  removed,  but 
there  does  not  appear  to  have  been  any  hemorrhage. — ED.] 

['  New  York  Med.  Repos.,  1817,  p.  388.] 


ABNORMAL    PREGNANCY.  171 

Opening  of  the  Sac  l>y  the  Gcdvano-caustic  Knife. — Dr.  Thomas,  of 
New  York,1  has  recently  recorded  a  most  instructive  case,  in  which 
he  saved  the  life  of  the  patient  by  a  bold  and  judicious  operation. 
The  nature  of  the  case  was  rendered  pretty  evident  by  the  signs 
above  described,  and  Thomas  opened  the  cyst  from  the  vagina  by  a 
platinum  knife,  rendered  incandescent  by  a  galvano-caustic  battery, 
by  which  means  he  hoped  to  prevent  hemorrhage.  Through  the 
opening  thus  made  he  removed  the  foetus.  In  subsequently  attempt- 
ing to  remove  the  placenta  very  violent  hemorrhage  took  place, 
which  was  only  arrested  by  injecting  the  cyst  with  a  solution  of 
persulphate  of  iron.  The  remains  of  the  placenta  subsequently  came 
away  piecemeal,  after  an  attack  of  septicaemia,  which  was  kept 
within  bounds  by  freely  washing  out  the  cyst  with  antiseptic  lotion, 
the  patient  eventually  recovering.  If  I  might  venture  to  make  a 
criticism  on  a  case  followed  by  so  brilliant  a  success,  it  would  be  that, 
in  another  instance  of  this  kind,  it  would  be  safer  to  follow  the  rule 
so  strictly  laid  down  with  regard  to  gastrotomy  in  abdominal  preg- 
nancies, and  leave  the  placenta  untouched,  trusting  to  the  injection  of 
antiseptics,  and  the  thorough  drainage  of  the  cyst,  to  prevent  mischief. 

[In  a  second  operation,  performed  on  May  10,  1876,  in  a  case  of 
secondary  abdominal  pregnancy,  Dr.  Thomas2  operated  through  the 
linea  alba,  and  removed  a  female  foetus  weighing  six  pounds,  fifteen 
ounces.  The  funis  was  traced  to  the  left  iliac  fossa,  where  it  was 
apparently  inserted  into  the  peritoneum,  and  no  placenta  was  dis- 
cernible. The  cord  was  cut  off  at  its  origin,  and  the  wound  closed, 
except  at  its  lower  part,  which,  was  kept  open  by  a  glass  tube.  The 
woman's  pulse  before  the  operation  was  120,  and  fell  to  107  at  the 
end  of  the  first  week;  temperature  was  always  100°  and  upwards, 
but  in  the  middle  of  the  fourth  week  it  rose  to  103°-104:0,  and  the 
pulse  to  130.  The  placenta  was  found  presenting  at  the  opening  in 
the  abdomen,  and  was  removed  with  dressing  forceps.  It  was  of  the 
ordinary  diameter,  and  had  a  shrivelled  appearance.  The  removal 
afforded  a  decided  relief,  and  the  temperature  fell  within  three  hours. 
Antiseptic  injections  were  freely  used  in  the  treatment  of  the  case, 
and  the  patient  made  a  good  recovery. 

The  advice  given  by  the  author  in  regard  to  the  non-removal  of 
the  placenta,  was  first  urged  upon  the  medical  profession,  so  far  as 
we  can  learn,  in  1795,  in  a3  letter  from  the  late  Dr.  James  Mease,  of 
Philadelphia,  to  Dr.  Lettsom,  of  London,  in  which  he  reported  an 
operation  by  Dr.  Charles  McKnight,  of  New  York,  very  similar  to 
this  of  Dr.  Thomas,  and  ending  favorably  to  the  woman.4  The 
remarks  of  Dr.  Mease  on  the  impropriety  of  removing  the  placenta 
were  read  before  the  Medical  Society  of  London,  and  concurred  in 
by  some  of  the  members  present. 

It  is  a  little  remarkable,  that  the  opinion  of  Dr.  Mease  originated 

'  New  York  Med  Journ.,  June,  1875. 
[2  Am.  Journ.  of  Obstetrics,  vol.  ix.  p.  655,  1876.] 
[3  Memoirs  of  Med.  Soc.  London,  vol.  4,  p.  342,  1795.] 

[4  More  recently  I  have  learned,  that  Mr.  William  Trumbull  made  the  same  re- 
commendation, before  the  said  Society,  in  1791.] 


172  PREGNANCY. 

in  an  accident  which  occurred  in  the  operation  of  Dr.  McKnight,  by 
which  the  funis  was  ruptured,  and  in  consequence  of  which,  the 
placenta,  which  was  outside  of  the  cyst,  could  not  be  found  for 
removal.  The  value  of  this  discovery  appears  to  have  been  lost  to 
the  profession  for  a  long  term  of  years,  as  many  authors  have  ob- 
jected to  the  operation  because  of  the  danger  of  removing  the  pla- 
centa.— ED.] 

Means  of  Destroying  the  Vitality  of  the  Foetus. — Another  mode  of 
managing  these  cases  is  to  destroy  the  foetus,  so  as  to  check  its 
further  growth,  in  the  hope  that  it  may  remain  inert  and  passive 
within  its  sac.  Various  operations  have  been  suggested  and  prac- 
tised for  this  purpose.  Thus  needles  have  been  introduced  into  the 
tumor,  through  which  currents  of  electricity  have  been  passed,  either 
the  continuous  current,  or,  as  has  been  suggested  by  Duchenne,  a 
spark  of  Franklinic  electricity.  Hicks,  Allen,  and  others  have 
endeavored  to  destroy  the  foetus  by  passing  an  electro-magnetic 
current  through  it  by  means  of  a  needle.  In  a  case  reported  by  Dr. 
Bachetti,  in  which  the  continuous  current  was  used,  the  growth  of 
the  ovum  was  arrested,  and  the  patient  recovered.  The  same  result, 
however,  would  probably  have  followed  the  simple  puncture  of  the 
cyst.  This  has  been  successfully  practised  on  several  occasions, 
either  with  a  small  trocar  and  canula,  or  with  a  simple  needle.  A 
very  interesting  case,  in  which  the  development  of  a  two  months' 
tubal  gestation  was  arrested  in  this  way,  is  recorded  by  Greenhalgh,1 
and  another  by  Martin,  of  Berlin.2  Joulin  suggested  that  not  only 
should  the  cyst  be  punctured,  but  that  a  solution  of  morphia  should 
be  injected  into  it,  which,  by  its  toxic  influence,  would  insure  the 
destruction  of  the  foetus.  Other  means  proposed  for  effecting  the 
same  object,  such  as  pressure,  or  the  administration  of  toxic  remedies 
by  the  mouth,  are  far  too  uncertain  to  be  relied  on.  The  simplest 
and  most  effectual  plan  would  be  to  introduce  the  needle  of  an 
aspirator,  by  which  the  liquor  amnii  would  be  drawn  off,  and  the 
further  growth  of  the  foetus  effectually  prevented.  Parry,3  indeed, 
is  opposed  to  this  practice,  and  has  collected  several  cases  in  which 
the  puncture  of  the  cyst  was  followed  by  fatal  results,  either  from 
hemorrhage  or  septicaemia.  In  these,  however,  an  ordinary  trocar 
and  canula  were  probably  employed,  which  would  necessarily  admit 
air  into  the  sac.  It  is  difficult  to  imagine  that  a  fine  hair-like  aspi- 
rating needle,  rendered  properly  antiseptic  by  carbolic  acid,  could 
have  any  injurious  results;  and  it  could  do  no  harm,  even  if  an 
error  of  diagnosis  had  been  made,  and  the  suspected  extra-uterine 
fcetation  turned  out  to  be  some  other  sort  of  growth.  If  the  aspirator 
proves  that  an  extra-uterine  foetation  exists,  then,  if  the  cyst  be  of 
any  considerable  size,  and  the  pregnancy  advanced  beyond  the 
second  month,  we  might,  if  deemed  advisable,  resort  to  a  more  radi- 
cal operation,  such  as  that  so  successfully  practised  by  Thomas. 

Treatment  when  Rupture  has  Occurred. — When  the  chance  of  arrest- 
ing the  growth  of  a  tubular  foetation  has  never  arisen,  and  we  first 

'•  Lancet,  1867.  2  Monat.  f.  Geburt,  1868. 

3  Parry  on  Extra-Uterine  Pregnancy,  p.  204. 


ABNORMAL    PREGNANCY.  173 

recognize  its  existence  after  laceration  has  occurred,  and  the  patient 
is  collapsed  from  hemorrhage,  what  course  are  we  to  pursue  ?  Hith- 
erto all  that  ever  has  been  done  is  to  attempt  to  rally  the  patient  by 
stimulants,  and,  in  the  unlikely  event  of  her  surviving  the  imme- 
diate effects  of  laceration,  endeavoring  to  control  the  subsequent 
peritonitis,  in  the  hope  that  the  effused  blood  may  become  absorbed, 
as  in  pelvic  htematocele.  This  is,  indeed,  a  frail  reed  to  rest  upon, 
and  when  laceration  of  a  tubal  gestation,  advanced  beyond  a  month, 
has  occurred,  death  has  been  the  almost  certain  result.  It  is  supposed 
by  Bernutz,  and  his  opinion  is  shared  by  Barnes,  that  rupture  which 
does  not  prove  fatal,  is  probably  not  very  rare  in  the  first  few  days 
of  extra-uterine  gestation,  and  that  it  is  not  an  uncommon  cause  of 
certain  forms  of  pelvic  hasmatocele.  It  has  more  than  once  been  sug- 
gested that  it  would  be  perfectly  justifiable  when  laceration  has  oc- 
curred to  perform  gastrotomy,  to  sponge  away  the  effused  blood,  and 
to  place  a  ligature  round  the  lacerated  tube  and  remove  it,  with  its 
contents.  This  would  no  doubt  be  a  bold  and  heroic  procedure,  but 
no  one  who  is  acquainted  with  the  triumphs  of  modern  abdominal 
surgery  can  say  that  it  would  be  either  impossible  or  hopeless.  The 
sponging  out  of  effused  blood  from  the  abdominal  cavity  is  an  every- 
day procedure  in  ovariotomy,  nor  is  there  any  apparent  difficulty  in 
ligaturing  and  removing  the  sac  of  the  extra-uterine  pregnancy,  for, 
as  a  rule,  there  are  no  adhesions  formed  to  the  surrounding  parts. 
The  history  of  these  cases  shows  that  death  does  not  generally  follow 
rupture  for  some  hours,  so  that  there  would  be  usually  time  for  the 
operation,  and  the  extreme  prostration  might  be,  perhaps,  tempo- 
rarily counteracted  by  transfusion.  Pressure  on  the  abdominal  aorta, 
resorted  to  when  the  patient  is  first  seen,  might  possibly  be  employed 
with  advantage  to  check  further  hemorrhage,  until  the  question  of 
operation  is  decided.  We  must  remember  that  the  alternative  is 
death  and  hence  any  operation  which  would  afford  the  slightest  hope 
of  success  would  be  perfectly  justifiable.  I  cannot,  therefore,  agree 
with  those  who  hold  that  because  the  chances  of  success  are  so  small, 
the  operation  should  not  be  tried ;  and  I  do  not  doubt  that  it  will 
yet  fall  to  the  lot  of  some  one,  by  this  means,  to  snatch  a  patient 
from  the  jaws  of  death,  and  still  further  to  extend  the  successes  of 
abdominal  surgery.1 

Abdominal  Pregnancy. — In  the  second  of  the  two  classes  into  which, 
for  practical  convenience,  we  have  divided  extra-uterine  gestation 
the  ovum  is  developed  in  the  abdominal  cavity.  It  is  as  yet  an  open 
question  whether  in  some  cases  the  pregnancy  is  primarily  abdominal 
or  not.  Barnes  believes  that  it  probably  never  is  so,  on  account  of 
the  difficulty  of  admitting  that  so  minute  a  body  as  the  ovum  should 
be  able  to  fix  itself  on  the  smooth  peritoneal  surface.  He  therefore 
thinks  that  all  abdominal  pregnancies  are  primarily  either  tubal  or 
ovarian,  the  sac  in  which  they  were  contained  having  given  way, 
and  the  ovum  having  retained  its  vitality  through  partial  attach- 

['  But  for  a  difference  of  views  in  consultation,  as  to  diagnosis  and  treatment,  this 
operation  would  have  been  performed  recently  by  Dr.  T.  G.  Thomas,  of  New  York. 
The  patient  lived  sixty  hours. — ED.] 


174  PREGNANCY. 

merit  to  the  original  sac.  This  theory  is  opposed  to  that  of  the  ma- 
jority of  writers,  and,  although  it  may  perhaps  render  the  facts  less 
difficult  to  understand,  it  is  purely  hypothetical.  There  is  no  evi- 
dence to  show  that  in  most  cases  there  is  an  early  laceration  of  a 
tubal  or  ovarian  sac.  That  the  chorion  villi  do  graft  themselves 
upon  the  surrounding  peritoneum  is  certain,  and  is  observed  in  all 
cases  of  abdominal  gestation.  It  is  not  more  difficult  to  imagine 
them  doing  this  from  their  very  first  development  than  a  little  later; 
for  it  must  be  allowed  that  if  such  laceration  does  occur,  in  most 
cases  it  can  only  be  when  pregnancy  is  very  slightly  advanced.  On 
the  whole,  therefore  it  seems  not  unreasonable  to  admit  the  usual 
explanation  of  these  cases,  that  the  ovule,  already  impregnated, 
escaped  the  grasp  of  the  Fallopian  tube,  and  fell  into  the  abdominal 
cavity,  where  it  rooted  itself  and  developed.  Some  have,  indeed, 
supposed  that  abdominal  pregnancy  may  occasionally  arise  in  conse- 
quence of  spermatozoa  finding  their  way  into  the  peritoneal  cavity, 
and  there  meeting  and  impregnating  an  ovule  discharged  from  the 
Graafian  follicle.  Such  an  event  one  would  suppose  to  be  almost  im- 
possible, but  Koeberle*'s  case,  already  quoted,  proves  that  it  has  actu- 
ally occurred.  The  probability  is  that  it  is  by  no  means  rare  for  impreg- 
nated ovules  to  drop  into  the  peritoneal  cavity,  and  that  the  majority 
of  those  that  do  so  perish  without  doing  any  harm.  When  they  do 
survive,  however,  the  chorion  villi  sprout,  attach  themselves  to  the 
surrounding  structures,  and  eventually  develope  into  a  placenta. 
The  mode  in  which  the  chorion  villi  are  attached,  and  the  arrange- 
ment of  the  maternal  bloodvessels,  have  never  yet  been  worked  out, 
and  would  form  a  very  interesting  subject  for  investigation.  The 
precise  seat  of  attachment  varies,  and  the  placenta  has  been  found 
fixed  to  most  of  the  abdominal  viscera,  either  those  contained  in  the 
pelvis  proper,  or  it  may  be  the  intestines,  or  to  the  iliac  fossa ;  most 
frequently,  apparently,  the  ovum  finds  its  way  into  the  retro-uterine 
cul-de-sac. 

Formation  of  a  Cyst  round  the  Ovum. — The  subsequent  changes 
vary  much.  In  the  large  majority  of  cases  the  ovum  produces  con- 
siderable irritation,  resulting  in  the  exudation  of  plastic  material, 
which  is  thrown  round  it,  so  as  to  form  a  secondary  cyst  or  capsule, 
in  which  maternal  vessels  are  largely  developed,  and  which  stretches, 
pari  passu,  with  the  growth  of  the  ovum  (Fig.  79).  The  density  and 
strength  of  this  cyst  are  found  to  be  very  different  in  different  cases ; 
sometimes  it  forms  a  complete  and  strong  covering  to  the  ovum,  at 
others  it  is  very  thin  and  only  partially  developed,  but  it  is  rarely 
entirely  absent.  As  there  is  ample  space  for  the  development  of  the 
ovum,  and  as  the  secondary  cyst  generally  stretches  and  grows  along 
with  it,  most  cases  of  abdominal  pregnancy  progress  without  any 
very  remarkable  symptoms,  beyond  occasional  severe  attacks  of  pain, 
until  the  full  term  of  pregnancy  has  been  reached.  Sometimes,  how- 
ever, the  cyst  lacerates,  and  there  is  an  escape  of  blood  into  the 
abdominal  cavity,  accompanied  by  more  or  less  prostration  and  col- 
lapse, which  may  prove  fatal,  but  from  which  the  patient  more  gen- 
erally rallies.  The  foetus,  now  dead,  will  remain  in  the  abdomen, 


ABNORMAL    PREGNANCY 


175 


and  will  undergo  changes  and  produce  results  similar  to  those  which 
we  shall  presently  describe  as  occurring  in  cases  progressing  to  the 
full  period. 


FIG.  79. 


Uterus  and  Foetus  in  a  Case  of  Abdominal  Preguaucy. 

Pseudo-labor  sometimes  comes  on. — In  most  cases  at  the  natural 
termination  of  pregnancy,  a  strange  series  of  phenomena  occur; 
pseudo-labor  comes  on,  there  are  more  or  less  frequent  and  strong 
uterine  contractions,  possibly  an  escape  of  blood  from  the  vagina,  the 
discharge  of  the  broken  down  uterine  decidua,  and  even  the  estab- 
lishment of  lactation.  Sometimes  the  contractions  of  the  abdominal 
muscles,  produced  by  this  ineffective  labor,  have  been  so  strong  as  to 
cause  the  laceration  of  the  adventitious  cyst  surrounding  the  foetus, 
and  the  escape  of  blood  and  liquor  amnii  into  the  abdominal  cavity, 
with  a  rapidly  fatal  result.  More  frequently  laceration  does  not 
occur,  and  the  spurious  labor  pains  continue  at  intervals,  until  the 
foetus  dies,  possibly  from  pressure,  but  more  often  from  effusion  of 
blood  into  the  tissue  of  the  placenta,  and  consequent  asphyxia.  Occa- 
sionally the  foetus  has  apparently  lived  a  considerable  time,  in  some 
cases  even  for  several  months,  after  the  natural  limit  of  pregnancy 
has  been  reached. 

Changes  after  the  Death  of  the  foetus. — It  is  after  the  death  of  the 
foetus  that  the  dangers  of  abdominal  pregnancy  generally  commence, 
and  they  are  numerous  and  various.  The  subsequent  changes  that 
occur  are  well  worthy  of  study.  Occasionally  the  foetus  has  been 
retained  for  a  length  of  time,  even  until  the  end  of  a  long  life,  with- 
out producing  any  serious  discomfort,  and  in  many  cases  of  this  kind 
several  normal  pregnancies  and  deliveries  have  subsequently  taken 
place.  Even  when  the  extra-uterine  gestation  appears  to  be  tolerated, 
and  has  remained  for  long  without  producing  any  bad  effects,  serious 
symptoms  may  be  suddenly  developed ;  so  that  no  woman,  under 
such  circumstances,  can  be  considered  safe.  The  condition  of  these 


176 


PREGNANCY. 


FiG.  80. 


retained  foetuses  varies  much.  Most  commonly  the  liquor  amnii  is 
absorbed,  the  foetus  shrinks  and  dies,  all  its  soft  structures  are  changed 
into  adipocere,  and  the  bones  only  remain  unaltered.  Sometimes 
this  change  occurs  with  great  rapidity.  I  have  elsewhere1  recorded 
a  case  of  extra-uterine  foetation  in  which  at  the  full  term  of  pregnancy 
the  foetus  was  alive,  and  the  woman  died  in  less  than  a  year  after- 
wards. On  post-mortem  the  foetus  was  found  entirely  transformed 
into  a  greasy  mass  of  adipocere,. studded  with  foetal  bones,  in  which 
not  a  trace  of  any  of  the  soft  parts  could  be  detected.  On  the  other 
hand  the  foetus  may  remain  unchanged;  in  the  Museum  of  the 
College  of  Surgeons  there  is  one  which  was  retained  in  the  abdomen 
for  fifty-two  years,  and  which  was  found  to  be  as  fresh  and  unaltered 
as  a  new-born  child.  In  other  cases  the  sac  and  its  contents  atrophy 
and  shrink,  and  calcareous  matter  is  deposited  in  them,  so  that  the 
whole  becomes  converted  into  a  solid  mass  known  as  a  lithopsedion 

(Fig.  80).  The  cases,  however,  in  which 
the  retention  of  the  foetus  gives  rise  to 
no  mischief  are  quite  exceptional.  Gene- 
rally the  foetus  putrefies,  and  this  may 
either  immediately  cause  fatal  peritonitis 
or  septicaemia ;  or,  as  more  commonly 
happens,  secondary  inflammation  and 
suppuration  of  the  sac.  Under  the  in- 
fluence of  the  latter  the  sac  opens  ex- 
ternally, either  directly  at  some  point  of 
the  abdominal  walls,  or  indirectly 
through  the  vagina,  the  bowels,  or  even 
the  bladder.  Through  the  aperture  or 
apertures  thus  formed  (for  there  are 
often  several  fistulous  openings),  pus, 
and  the  bones  and  other  parts  of  the 
broken-down  foetus,  are  discharged ;  and 
this  may  go  on  for  mouths,  and  even 
years,  until  at  last,  if  the  patient's 
strength  does  not  give  way,  the  whole 
contents  of  the  cyst  are  expelled,  and 
recovery  takes  place.  From  various  statistical  observations  it  ap- 
pears, that  the  chances  of  recovery  are  best  when  the  cyst  opens 
through  the  abdominal  walls,  next  through  the  vagina  or  bladder, 
and  that  the  foetus  is  discharged  with  most  difficulty  and  danger  when 
the  aperture  is  formed  into  the  bowel.  At  the  best,  however,  the 
process  is  long,  tedious,  and  full  of  dangers ;  and  the  patient  too  often 
sinks,  during  the  attempt  at  expulsion,  through  the  irritation  and 
exhaustion  produced  by  the  abundant  and  long-continued  discharge. 
Diagnosis. — The  diagnosis  of  abdominal  gestation  is  by  no  means 
so  easy  as  might  be  thought,  and  the  most  experienced  practitioners 
have  been  mistaken  with  regard  to  it. 

The  most  characteristic  symptom,  although  this  is  not  so  common 


Lithopsedion. 

(From  a  preparation  in  the  Museum  of 
the  College  of  Surgeons.) 


1  Obst.  Trans   vii. 


ABNORMAL    PREGNANCY.  177 

as  in  tubal  gestation,  is  metrorrhagia,  combined  with  the  general 
signs  of  pregnancy.  Very  severe  and  frequently  repeated  attacks 
of  abdominal  pain  are  rarely  absent,  and  should  at  once  cause  sus- 
picion, especially  if  associated  with  hemorrhage.  They  are  supposed 
by  some  to  depend  on  intercurrent  attacks  of  peritonitis,  by  which 
the  foetal  cyst  is  formed.  Parry  doubts  this  explanation,  and  attrib- 
utes them  partly  to  the  distension  of  the  cyst  by  the  growing  foetus, 
and  partly  to  pressure  on  the  surrounding  structures.  On  palpation 
the  form  of  the  abdomen  will  be  observed  to  differ  from  that  of  nor- 
mal pregnancy,  being  generally  more  developed  in  the  transverse 
direction,  and  the  rounded  outline  of  the  gravid  uterus  cannot  be 
detected.  When  development  has  advanced  nearly  to  term,  the  ex- 
treme distinctness  with  which  the  foetal  limbs  can  be  felt  will  arouse 
suspicion.  Per  vaginam  the  os  and  cervix  will  be  felt  softened  as  in 
ordinary  pregnancy,  but  often  displaced  by  the  pressure  of  the  cyst, 
and  sometimes  fixed  by  peri-metritic  adhesions ;  either  of  these  signs 
is  of  great  diagnostic  value. 

By  bimanual  examination  it  may  be  possible  to  make  out  that  the 
uterus  is  not  greatly  enlarged,  and  that  it  is  distinctly  separate  from 
the  bulk  of  the  tumor ;  these  facts,  if  recognized,  would  of  them- 
selves disprove  the  existence  of  uterine  gestation.  The  diagnosis,  if 
the  foetal  limbs  or  heart-sounds  could  be  detected,  would  be  cleared 
up  in  any  case  by  the  uterine  sound,  which  would  show  that  the 
uterus  was  empty  and  only  slightly  elongated.  But  we  must  be  care- 
ful not  to  resort  to  this  test  unless  the  existence  of  uterine  gestation 
is  positively  disproved  by  other  means.  As,  however,  it  places  the 
diagnosis  beyond  a  doubt,  it  should  always  be  employed  whenever 
operative  procedure  is  in  contemplation. 

Treatment. — The  treatment  of  abdominal  gestation  will  always  be 
a  subject  of  anxious  consideration,  and  there  is  much  difference  of 
opinion  as  to  the  proper  course  to  pursue.  It  is  pretty  generally 
admitted  that  it  is  not  advisable  to  adopt  any  active  measures  until 
the  full  term  of  development  is  reached.  Puncturing  the  cyst,  with 
the  view  of  destroying  the  foetus  and  arresting  its  further  growth, 
has  been  practised,  but  there  are  good  grounds  for  rejecting  it,  for 
there  is  not  the  same  imminent  risk  of  death  from  rupture  of  the 
cyst  as  in  tubal  fcetation ;  and  even  if  the  destruction  of  the  foetus 
could  be  brought  about,  there  would  still  be  formidable  dangers  from 
subsequent  attempts  at  elimination,  or  from  internal  hemorrhage. 

Primary  Gastrotomy. — When  the  full  period  has  arrived,  the  child 
being  still  alive,  as  proved  by  auscultation,  we  have  to  consider 
whether  it  may  not  be  advisable  to  perform  gastrotomy  before  the 
foetus  perishes,  and  so  at  least  save  the  life  of  the  child.  There  are 
few  questions  of  greater  importance,  and  more  difficult  to  settle.  The 
tendency  of  medical  opinion  is  rather  in  favor  of  immediate  opera- 
tion, which  is  recommended  by  Yelpeau,  Kiwisch,  Koeberle,  Schroe- 
der,  and  many  other  writers,  whose  opinion  necessarily  carries  great 
weight.  The  arguments  used  in  favor  of  immediate  operations  are 
that,  while  it  affords  a  probability  of  saving  the  child,  the  risks  to 
the  mother,  great  though  they  undoubtedly  are,  are  not  greater  than 


178  PREGNANCY. ' 

those  which  may  be  anticipated  by  delay.  If  we  put  off  interference 
the  cyst  may  rupture  during  the  ineffectual  efforts  at  labor,  and  death 
at  once  ensue  ;  or,  if  this  does  not  take  place,  other  risks,  which  can 
never  be  foreseen,  are  always  in  store  for  the  patient.  She  may  sink 
from  peritonitis,  or  from  exhaustion,  consequent  on  the  efforts  at 
elimination,  which  in  the  majority  of  cases  are  sooner  or  later  set  up, 
so  that,  as  Barnes  properly  says,  "  the  patient's  life  may  be  said  to 
be  at  the  mercy  of  accidents,  of  which  we  have  no  sufficient  warn- 
ing." On  the  other  hand,  if  we  delay,  while  we  sacrifice  all  hope  of 
saving  the  child,  we  at  least  give  the  mother  the  chance  of  the  fceta- 
tion  remaining  quiescent  for  a  length  of  time,  as  certainly  not  infre- 
quently occurs.  Thus,  Campbell  collected  62  cases  of  ultimate  re- 
covery after  abdominal  gestation,  in  21  of  which  the  foetus  was 
retained  without  injury  for  a  number  of  years.  Then  there  is  the 
question  of  secondary  gastrotomy,  which  consists  in  operating  after 
the  death  of  the  foetus  when  urgent  symptoms  have  arisen,  a  course 
which  is  advocated  by  Mr.  Hutchinson.  In  favor  of  this  procedure 
it  is  urged,  that  by  delay  the  inflammation  taking  place  about  the 
cyst  will  have  greatly  increased  the  chance  of  adhesions  having 
formed  between  it  and  the  abdominal  parietes.  so  as  to  shut  off'  its 
contents  from  the  cavity  of  the  peritoneum.  The  more  effectually 
this  has  been  accomplished,  the  greater  are  the  patient's  chances  of 
recovery.  When  the  foetus  has  been  dead  for  some  time  the  vascu- 
larity  of  the  cyst  will  also  be  lessened,  and  the  placental  circulation 
will  have  ceased,  so  that  the  danger  of  hemorrhage  will  be  much 
diminished. 

It  will  be  seen,  therefore,  that  there  are  arguments  in  favor  of 
each  of  these  views.  The  results  of  the  primary  operation  are  far 
less  favorable  than  we  should  have,  a  priori,  supposed.  Since  the 
first  edition  of  this  work  appeared  the  subject  has  been  carefully 
studied  by  Dr.  Parry  in  his  exhaustive  treatise  on  Extra-Uterine 
Fcetation.  He  has  there  shown  that  when  the  case  is  left  until 
nature  has  shown  the  channel  through  which  elimination  is  to  be 
effected,  the  mortality  is  17.35  less  than  in  the  cases  in  which  the 
primary  operation  was  performed.  His  conclusion  is,  that  "  the  pri- 
mary operation  cannot  be  too  forcibly  condemned.  It  is  not  too  much 
to  say  that  this  operation  adds  only  another  danger  to  a  life  already 
trembling  in  the  balance,  which  the  delusive  hope  of  saving  the  un- 
certain life  of  a  child  does  not  warrant  us  in  assuming."  It  is  only 
just  to  remember,  as  is  forcibly  pointed  out  by  Keller,  that  in  these 
days  of  advanced  abdominal  surgery  a  better  result  might  be  antici- 
pated than  when  gastrotomy  was  performed  in  the  haphazard  way 
which  was  usual  before  we  had  gained  experience  from  ovariotomy. 
No  doubt  minute  care  in  the  performance  of  the  operation,  a  due 
attention  to  its  details,  studiously  avoiding,  as  much  as  possible,  the 
passage  of  blood  and  the  contents  of  the  cyst  into  the  peritoneal 
cavity,  would  materially  lessen  its  peril. 

Mode  of  performing  the  Operation. — The  operation,  then,  should  be 
performed  with  all  the  precautions  with  which  we  surround  ovari- 
otomy. The  incision,  best  made  in  the  linea  alba,  should  not  be 


ABNORMAL    PREGNANCY.  179 

greater  than  is  necessary  to  extract  the  foetus,  and  maybe  lengthened 
as  occasion  requires.  If  there  are  no  adhesions  the  walls  of  the  cyst 
should  be  stitched  to  the  margin  of  the  incision,  so  as  to  shut  it  off 
as  completely  as  possible  from  the  peritoneal  cavity.  This  has  been 
specially  insisted  on  by  Braxton  Hicks,  and  should  never  be  omitted. 
The  special  risk  is  not  so  much  the  wounding  of  the  peritoneum,  as 
the  subsequent  entrance  of  septic  matter  from  the  cyst  into  its  cavity. 
Another  cardinal  rule,  both  in  primary  and  secondary  gastrotomy, 
is  to  make  no  attempt  to  remove  the  placenta.  Its  attachments  are 
generally  so  deep-seated  and  diffused,  that  any  endeavor  to  separate 
it  is  likely  to  be  attended  with  profuse  and  uncontrollable  hemorrhage, 
or  with  serious  injury  to  the  structures  to  which  it  is  attached.  Many 
of  the  failures  after  operating  can  be  traced  to  a  neglect  of  this  rule. 
The  best  subsequent  course  to  pursue,  after  removing  the  foetus,  and 
arresting  all  hemorrhage,  either  by  ligature  or  the  actual  cautery,  is 
to  sponge  out  the  cyst  as  gently  as  possible,  and  then  to  bring  the 
upper  part  of  the  wound  into  apposition  with  sutures,  leaving  the 
lower  open,  with  the  cord  protruding,  so  as  to  insure  an  outlet  for 
the  escape  of  the  placenta  as  it  slips  down.  The  subsequent  treat- 
ment must  be  specially  directed  to  favor  the  escape  of  the  discharge, 
and  to  prevent  the  risk  of  septicaemia.  These  objects  may  be  much 
aided  by  injections  of  antiseptic  fluids,  such  as  a  solution  of  carbolic 
acid,  or  diluted  Condy's  fluid ;  and  it  would  perhaps  be  advisable  to 
place  a  drainage  tube  in  the  lower  angle  of  the  wound.  It  may  be 
well  to  point  out  that  there  is  no  operation  in  which  a  scrupulous 
.following  of  the  antiseptic  method,  on  Mr.  Lister's  principles,  is  so 
likely  to  be  useful. 

Treatment  when  the  Foetus  is  Dead. — As  long  as  the  placenta  is  re- 
tained the  danger  is  necessarily  great,  and  it  may  be  many  days  or 
even  weeks  before  it  is  discharged.  When  once  this  is  effected  the 
sac  may  be  expected  to  contract,  and  eventually  to  close  entirely. 

When  the  foetus  is  dead,  or  when  we  have  determined  not  to  attempt 
primary  gastrotomy,  it  is  advisable  to  wait,  very  carefully  watching 
the  patient,  until  either  the  gravity  of  her  general  symptoms,  or  some 
positive  indication  of  the  channel  through  which  nature  is  about  to 
attempt  to  eliminate  the  foetus,  shows  us  that  the  time  for  action  has 
arrived.  If  there  be  distinct  bulging  of  the  cyst  in  the  vagina,  or  in 
the  retro-vaginal  cul-de-sac,  especially  if  an  opening  has  formed  there, 
we  may  properly  content  ourselves  with  aiding  the  passage  of  the 
foetus  through  the  channel  thus  indicated,  and  removing  the  parts 
that  present  piecemeal  as  they  come  within  reach,  cautiously  enlarg- 
ing the  aperture  if  necessary.  If  the  sac  have  opened  into  the  intes- 
tines, the  expulsion  of  the  foetus  through  this  channel  is  so  tedious 
and  difficult,  the  exhaustion  attending  it  so  likely  to  prove  fatal,  and 
the  danger  from  decomposition  of  the  foetus  through  passage  of  in- 
testinal gas  so  great,  that  it  would  probably  be  best  to  attempt  to 
remove  it  by  gastrotomy,  especially  if  it  is  only  recently  dead,  and 
the  greater  portion  is  still  retained. 

Mode  of  performing  Secondary  Gastrotomy. — If  an  opening  forms 
at  the  abdominal  parietes,  or  if  the  symptoms  determine  us  to  resort 


180  PREGNANCY. 

to  secondary  gastrotomy  betbre  this  occurs,  the  operation  must  be 
performed  in  the  same  way,  and  with  the  same  precautions,  as  primary 
gastrotomy.  Here,  as  before,  the  safety  of  the  operation  must  greatly 
depend  on  the  amount  and  firmness  of  the  adhesions;  for  if  the  cyst 
be  not  completely  shut  off  from  the  peritoneal  cavity,  the  risks  of  the 
operation  will  be  little  less  than  those  of  primary  gastrotomy.  It 
would  obviously  materially  influence  our  decision  and  prognosis  if 
we  could  determine  this  point  before  operating.  Unfortunately  it  is 
impossible,  as  the  experience  of  ovariotomists  proves,  to  ascertain 
the  existence  of  adhesions  with  any  certainty.  If,  however,  we  find 
that  the  abdominal  parietes  do  not  move  freely  over  the  cyst,  and  if 
the  umbilicus  be  depressed  and  immovable,  the  presumption  is  that 
considerable  adhesions  exist.  If  they  are  found  not  to  be  present, 
the  cyst  walls  should  be  stitched  to  the  margin  of  the  incision,  in  the 
manner  already  indicated,  before  the  contents  are  removed. 

If  the  foetus  has  been  long  dead,  and  its  tissues  greatly  altered,  its 
removal  may  be  a  matter  of  difficulty.  In  the  case  under  my  own 
care,  already  alluded  to.  the  foetal  structures  formed  a  sticky  mass 
of  such  a  nature,  that  I  believe  it  would  have  been  impossible  to 
empty  the  cyst  had  an  operation  been  attempted.  This  possibility 
would  be,  to  some  extent,  a  further  argument  in  favor  of  the  primary 
operation. 

Opening  of  Cyst  by  Caustics. — The  importance  of  adhesion  has  led 
some  practitioners  to  recommend  the  opening  of  the  cyst  by  potassa 
fusa  or  some  other  caustic,  in  the  hope  that  it  would  set  up  adhesive 
inflammation  around  the  apertures  thus  formed.  Several  successful 
operations  by  this  method  are  recorded,  and  it  would  be  worth 
trying,  should  the  extreme  mobility  of  the  cyst  lead  us  to  suspect 
that  no  adhesions  existed.  If  we  have  to  deal  with  a  case  in  which 
fistulous  openings  leading  to  the  cyst  have  already  formed,  it  may, 
perhaps,  be  advisable  to  dilate  the  apertures  already  existing,  rather 
than  make  a  fresh  incision ;  but,  in  determining  this  point,  the  sur- 
geon will  naturally  be  guided  by  the  nature  of  the  case,  and  the 
character  and  direction  of  the  fistulous  openings. 

General  Treatment. — It  is  almost  needless  to  say  anything  of 
general  treatment  in  these  trying  cases;  but  the  administration  of 
opiates  to  allay  the  sufferings  of  the  patient,  and  the  endeavor  to 
support  the  severely  taxed  vital  energies  by  appropriate  food  and 
medication,  will  form  a  most  important  part  of  the  management. 

Gestation  in  a  Bi-lobed  Uterus. — A  few  words  may  be  said  as  to 
gestation  in  the  rudimentary  horn  of  a  bi-lobed  uterus,  to  which 
considerable  attention  has  of  late  years  been  directed  by  the  writings 
of  Kussmaul  and  others.  It  appears  certain  that  many  cases  of 
supposed  tubal  gestation  are  really  to  be  referred  to  this  category. 
Although  such  cases  are  of  interest  pathologically,  they  scarcely  re- 
quire much  discussion  from  a  practical  point  of  view,  inasmuch  as 
their  history  is  pretty  nearly  identical  with  that  of  tubal  pregnancy. 
The  rudimentary  horn  is  distended  by  the  enlarging  ovum,  and  after 
a  time,  when  further  distension  is  impossible,  laceration  takes  place. 
As  a  matter  of  fact,  all  the  13  cases  collected  bv  Kussmaul  termi- 


ABNORMAL    PREGNANCY.  181 

nated  in  this  way ;  and  even  on  post-mortem  examination  it  is  often 
extremely  difficult  to  distinguish  them  from  tubal  pregnancies.  The 
best  way  of  doing  so  is  probable  by  observing  the  relations  of  the 
round  ligaments  to  the  tumor,  for,  if  the  gestation  be  tubal,  they  will 
be  found  attached  to  the  uterus  on  the  inner  or  uterine  side  of  the 
cyst ;  whereas,  if  the  pregnancy  be  in  a  rudimentary  horn  of  the 
uterus,  the}*"  will  be  pushed  outwards  and  be  external  to  the  sac.  In 
the  latter  case,  moreover,  the  sac  will  be  probably  found  to  contain 
a  true  decidua,  which  is  not  the  case  in  tubal  pregnancy.  The  only 
point  in  which  they  differ  is  that  in  cornual  pregnancy  rupture  may 
be  delayed  to  a  somewhat  later  period  than  in  tubal,  on  account  of 
the  greater  distensibility  of  the  supplementary  horn. 

Missed  Labor.— The  term  "missed  labor"  is  applied  to  an  exceed- 
ingly rare  class  of  cases  in  which,  at  the  full  period  of  pregnancy,  labor 
has  either  not  come  on  at  all,  or,  having  commenced,  the  pains  have 
subsequently  passed  off,  and  the  foetus  is  retained  in  utero  for  a  very 
considerable  length  of  time.  Under  such  circumstances  it  has  usually 
happened  that  the  membranes  have  ruptured  at  or  about  the  proper 
term,  and  the  access  of  air  to  the  foetus  in  utero  has  been  followed 
by  decomposition.  A  putrid  and  offensive  discharge  has  then  com- 
menced, and  eventually  portions  of  the  disintegrating  foetus  have 
been  expelled  per  vaginam.  This  discharge  may  go  on  until  the 
entire  foetus  is  gradually  thrown  off;  or,  more  frequently,  the  patient 
dies  from  septicasmia,  or  other. secondary  result  of  the  presence  of  the 
decomposing  mass  in  utero. 

Thus  McClintock  relates  one  case,1  in  which  symptoms  of  labor 
came  on  in  a  woman,  45  years  of  age,  at  the  expected  period  of  de- 
livery, but  passed  off  without  the  expulsion  of  the  foetus.  For  a 
period  of  sixty-seven  weeks  a  highly  offensive  discharge  came  away, 
with  some  few  bones,  and  she  eventually  died  with  symptoms  of 
pyaemia.  He  also  cites  another  case  in  which  the  patient  died  in  the 
same  way,  after  the  foetus  had  been  retained  for  eleven  years. 

Ulceration  of  the  Uterine  Walls. — Sometimes,  when  the  foetus  has 
been  retained  for  a  length  of  time,  a  further  source  of  danger  has 
been  added  by  ulceration  or  destruction  of  the  uterine  walls,  proba- 
bly in  consequence  of  an  ineffectual  attempt  at  its  elimination.  This 
occurred  in  Dr.  Oldham's  case  (Fig.  81),  in  which  the  contained  mass 
is  said  to  have  nearly  worn  through  the  anterior  wall  of  the  uterus; 
and  also  in  one  reported  by  Sir  Jarnes  Simpson,2  in  which  a  patient 
died  three  months  after  term,  the  foetus  having  undergone  fatty  meta- 
morphosis, an  opening  the  size  of  half-a-crown  having  formed  between 
the  transverse  colon  and  the  uterine  cavity.  It  is  also  stated  that 
"the  uterine  walls  were  as  thin  as  parchment." 

In  some  few  cases,  however,  probably  when  the  entrance  of  air 
has  been  prevented,  the  foetus  has  been  retained  for  a  length  of  time 
without  decomposing,  and  without  giving  rise  to  any  troublesome 
symptoms.  Such  a  case  is  reported  by  Dr.  Cheston,3  in  which  the 
foetus  remained  in  utero  for  fifty-two  years. 

1  Doublin  Quart.  Journ.,  Feb.  and  May,  18(54. 

2  Edin.  Med.  Journ.,  1865.  *    3  Med.  Chir.  Trans.,  1814. 


182 


PREGNANCY. 


Its  Causes. — The  causes  of  this  strange  occurrence  are  altogether 
unknown.  Generally  the  foetus  seems  to  have  died  sometime  before 
the  proper  term  for  labor,  and  this  may  have  influenced  the  character 
of  the  pains.  It  is  probably  also  most  apt  to  occur  in  women  of 

FIG.  81. 


Contents  of  the  Cyst  in  Dr.  Oldham't*  case  of  Missed  Labor. 

feeble  and  inert  habit  of  body,  possibly  where  there  was  some  obstacle 
to  the  dilatation  of  the  cervix,  which  the  pains  were  unable  to  over- 
come. Barnes  suggests1  that  some  presumed  examples  of  missed 
labor  "  were  really  cases  of  interstitial  gestation,  or  gestation  in  one 
horn  of  a  two-horned  uterus."  In  several  of  the  cases,  however,  the 
details  of  the  post-mortem  examination  are  too  minute  to  admit  of 
the  possibility  of  this  mistake  having  been  made. 

From  what  has  been  said,  it  will  be  seen  that  the  dangers  arising 
from  this  state  are  very  considerable,  and  when  once  the  full  term 
has  passed  beyond  doubt,  especially  if  the  presence  of  an  offensive 
discharge  shows  that  decomposition  of  the  fcetus  has  commenced,  it 
would  be  proper  practice  to  empty  the  uterus  as  soon  as  possible. 
The  necessary  precaution,  however,  is  not  to  decide  too  quickly  that 
the  term  has  really  passed;  and,  therefore,  we  must  either  allow 
sufficient  time  to  elapse  to  make  it  quite  certain  that  the  case 
really  falls  under  this  category,  or  have  unequivocal  signs  of  the 
death  of  the  fcetus,  and  injury  to  the  mother's  health.  If  \ve  had  to 
deal  with  the  case  before  any  extensive  decomposition  of  the  foetus 

1  Diseases  of  Women,  p.  445. 


DISEASES    OF    PREGNANCY.  183 

had  occurred,  we  probably  should  find  little  difficulty  in  its  manage- 
ment, for  the  proper  course  then  would  be  to  dilate  the  cervix  with 
the  fluid  dilators,  and  remove  the  foetus  by  turning;  or,  before  doing 
so,  we  might  endeavor  to  excite  uterine  action  by  pressure  and  ergot. 
If  the  case  did  not  come  under  observation  until  disintegration  of  the 
foetus  had  begun,  it  would  be  more  difficult  to  deal  with.  If  the  foetus 
had  become  so  much  broken  up  that  it  was  being  discharged  in  pieces, 
Dr.  McClintock  says  that  "in  regard  to  treatment,  our  measures  should 
consist  mainly  of  palliatives,  viz.,  rest  and  hip-baths  to  subdue  uterine 
irritation;  vaginal  injections  to  secure  cleanliness  and  prevent  ex- 
coriation; occasional  digital  examination,  so  as  to  detect  any  frag- 
ments of  bone  that  might  be  presenting  at  the  os,  and  to  assist  in 
removing  them.  These  are  plain  rational  measures,  and  beyond 
them  we  shall  scarcely,  perhaps,  be  justified  in  venturing.  Never- 
theless, under  certain  circumstances,  I  would  not  hesitate  to  dilate 
the  cervical  canal  so  as  to  permit  of  examining  the  interior  of  the 
womb,  and  of  extracting  any  fragments  of  bone  that  may  be  easily 
accessible;  but  unless  they  could  thus  be  easily  reached  and  removed, 
the  safer  course  would  be  to  defer,  for  the  present,  interfering  with 
them.1 

It  may  be  doubted,  I  think,  whether,  considering  the  serious 
results  which  are  known  to  have  followed  so  many  cases,  it  would 
not,  on  the  whole,  be  safer  to  make  at  least  one  decided  effort,  under 
chloroform,  to  remove  as  much  as  possible  of  the  putrefying  uterine 
contents,  after  the  os  has  been  fully  dilated.  Such  a  procedure  would 
be  less  irritating  than  frequently  repeated  endeavors  to  pick  away 
detached  portions  of  the  foetus,  as  they  present  at  the  os  uteri. 
When  once  the  os  is  dilated,  antiseptic  intra-uterine  injections,  as 
of  diluted  Condy's  fluid,  might  safely  and  advantageously  be  used. 
Unquestionably,  it  would  be  better  practice  to  interfere  and  empty 
the  uterus  as  soon  as  we  are  quite  satisfied  of  the  nature  of  the  case, 
rather  than  to  delay,  until  the  foetus  has  been  disintegrated. 


CHAPTER  VII. 

DISEASES  OF  PREGNANCY. 

THE  diseases  of  pregnancy  form  a  subject  so  extensive  that  they 
might  well  of  themselves  furnish  ample  material  for  a  separate 
treatise.  The  pregnant  woman  .is,  of  course,  liable  to  the  same 
diseases  as  the  non-pregnant;  but  it  is  only  necessary  to  allude  to 
those  whose  course  and  effects  are  essentially  modified  by  the  exist- 

1  Dublin  Quart.  Journ.,  vol.  xxxvii.  p.  314. 


184  PREGNANCY. 

encc  of  pregnancy,  or  which  have  some  peculiar  effect  on  the  patient 
in  consequence  of  her  condition.  There  are,  moreover,  many  dis 
orders  which  can  be  distinctly  traced  to  the  existence  of  pregnancy. 
Some  of  them  are  the  direct  results  of  the  sympathetic  irritations 
which  are  then  so  commonly  observed;  and,  of  these,  several  are 
only  exaggerations  of  irritations  which  may  be  said  to  be  normal 
accompaniments  of  gestation.  These  functional  derangements  may 
be  classed  under  the  head  of  neuroses,  and  they  are  sometimes  so 
slight  as  merely  to  cause  temporary  inconvenience,  at  others  so  grave 
as  seriously  to  imperil  the  life  of  the  patient.  Another  class  of 
disorders  are  to  be  traced  to  local  causes  in  connection  writh  the 
gravid  uterus,  and  are  either  the  mechanical  results  of  pressure,  or 
of  some  displacement,  or  morbid  state  of  the  uterus.  While  the 
origin  of  others  may  be  said  to  be  complex,  being  partly  due  to 
sympathetic  irritation,  partly  to  pressure,  and  partly  to  obscure 
nutritive  changes  produced  by  the  pregnant  state. 

Derangements  of  the  Digestive  System. — Among  the  sympathetic 
derangements  there  are  none  which  are  more  common,  and  none 
which  more  frequently  produce  distress,  and  even  danger,  than  those 
which  affect  the  digestive  system.  Under  the  heading  of  "The  Signs 
of  Pregnancy,"  the  frequent  occurrence  of  nausea  and  vomiting  has 
already  been  discussed,  and  its  most  probable  causes  considered  (p. 
135).  A  certain  amount  of  nausea  is,  indeed,  so  common  an  accom- 
paniment of  pregnancy,  that  its  consideration  as  one  of  the  normal 
symptoms  of  that  state  is  fully  justified.  We  need  here  only  discuss 
those  cases  in  which  the  nausea  is  excessive  and  long-continued,  and 
leads  to  serious  results  from  inanition,  and  from  the  constant  distress 
it  occasions.  Fortunately  a  pregnant  woman  may  bear  a  surprising 
amount  of  nausea  and  sickness  without  constitutional  injury,  so  that 
apparently  almost  all  aliments  may  be  rejected,  without  the  nutrition 
of  the  body  very  materially  suffering.  At  times  the  vomiting  is 
limited  to  the  early  part  of  the  day,  when  all  food  is  rejected,  and 
when  there  is  a  frequent  retching  of  glairy  transparent  fluid,  in 
severe  cases  mixed  with  bile,  while  at  the  latter  part  of  the  day  the 
stomach  may  be  able  to  retain  a  sufficient  quantity  of  food,  and  the 
nausea  disappears.  In  other  cases  the  nausea  and  vomiting  are 
almost  incessant.  The  patient  feels  constantly  sick,  and  the  mere 
taste  or  sight  of  food  may  bring  on  excessive  and  painful  vomiting. 
The  duration  of  this  distressing  accompaniment  of  pregnancy  is  also 
variable.  Generally  it  commences  between  the  second  and  third 
months,  and  disappears  after  the  woman  has  quickened.  Sometimes, 
however,  it  begins  with  conception,  and  continues  unabated  until 
the  pregnancy  is  over. 

/Symptoms  of  the  Graver  Cases. — In  the  worst  class  of  cases,  when 
all  nourishment  is  rejected,  and  when  the  retching  is  continuous  and 
painful,  symptoms  of  very  great  gravity,  which  may  even  prove 
fatal,  develope  themselves.  The  countenance  becomes  haggard  from 
suffering,  the  tongue  dry  and  coated,  the  epigastrium  tender  on  pres- 
sure, and  a  state  of  extreme  nervous  irritability,  attended  with  rest- 
lessness and  loss  of  sleep,  becomes  established.  In  a  still  more  aggra- 


DISEASES    OF    PREGNANCY.  185 

vated  degree,  there  is  general  feverishness,  with  a  rapid,  small,  and 
thready  pulse.  Extreme  emaciation  supervenes,  the  result  of  wast- 
ing from  lack  of  nourishment.  The  breath  is  intensely  fetid,  and 
the  tongue  dry  and  black.  The  vomited  matters  are  sometimes 
mixed  with  blood.  The  patient  becomes  profoundly  exhausted,  a 
low  form  of  delirium  ensues,  and  death  may  follow  if  relief  is  not 
obtained. 

Prognosis. — Symptoms  of  such  gravity  are  fortunately  of  extreme 
rarity,  but  they  do  from  time  to  time  arise,  and  cause  much  anxiety. 
Gueniot  collected  118  cases  of  this  form  of  the  disease,  out  of  which 
46  died ;  and  out  of  the  72  that  recovered,  in  42  the  symptoms  only 
ceased  when  abortion,  either  spontaneous,  or  artificially  produced, 
had  occurred.  When  pregnancy  is  over  the  symptoms  occasionally 
cease  with  marvellous  rapidity.  The  power  of  retaining  and  assimi- 
lating food  is  rapidly  regained,  and  all  the  threatening  symptoms 
disappear. 

Treatment. — In  the  milder  forms  of  obstinate  vomiting,  one  of  the 
first  indications  will  be  to  remedy  any  morbid  state  of  the  primae 
via?.  The  bowels  will  not  infrequently  be  found  to  be  obstinately 
constipated,  the  tongue  loaded,  and  the  breath  offensive ;  and  when 
attention  has  been  paid  to  the  general  state  of  the  digestive  organs 
by  gentle  aperient  medicines,  and  antacid  remedies,  such  as  bismuth 
and  soda,  and  pepsine  after  meals,  the  tendency  to  vomiting  may 
abate  without  further  treatment. 

Regulation  of  Diet. — The  careful  regulation  of  the  diet  is  very  im- 
portant. Great  benefit  is  often  derived  from  recommending  the 
patient  not  to  rise  from  the  recumbent  position  in  the  morning  until 
she  has  taken  something.  Half  a  cup  of  milk  and  lime-water,  or  a 
cup  of  strong  coffee,  or  a  little  rum  and  milk,  or  cocoa  and  milk,  or 
even  a  morsel  of  biscuit,  taken  on  waking,  often  has  a  remarkable 
effect  in  diminishing  the  nausea.  When  any  attempt  at  swallowing 
solid  food  brings  on  vomiting,  it  is  better  to  give  up  all  pretence  at 
keeping  to  regular  meals,  and  to  order  such  light  and  easily  assimi- 
lated food,  at  short  intervals,  as  can  be  retained.  Iced  milk  with 
lime  or  soda-water,  given  frequently,  and  not  more  than  a  mouthful 
at  a  time,  will  frequently  be  retained  when  nothing  else  will.  Cold 
beef  jelly,  a  spoonful  at  a  time,  will  also  be  often  kept  down.  Spark- 
ling koumiss  has  been  strongly  recommended  as  very  useful  in  such 
cases,  and  is  worthy  of  trial.  It  is  well,  however,  to  bear  in  mind, 
in  regulating  the  diet,  that  the  stomach  is  fanciful  and  capricious, 
and  that  the  patient  may  be  able  to  retain  strange  and  apparently 
unlikely  articles  of  food ;  and  that,  if  she  express  a  desire  for  such, 
the  experiment  of  letting  her  have  them  should  certainly  be  tried. 

Medicinal  Treatment. — The  medicines  that  have  been  recommended 
are  innumerable,  and  the  practitioner  will  often  have  to  try  one  after 
the  other  unsuccessfully ;  or  may  find,  in  an  individual  case,  that  a 
remedy  will  prove  valuable  which,  in  another,  may  be  altogether 
powerless.  Amongst  those  most  generally  useful  are  effervescing 
draughts,  containing  from  three  to  five  minims  of  dilute  hydrocyanic 
acid ;  the  creasote  mixture  of  the  Pharmacopoeia ;  tincture  of  nux. 
13 


186  PREGNANCY. 

vomica,  in  doses  of  five  to  ten  minims;  single  minim  doses  of  vinum 
ipecacuanhas,  every  hour  in  severe  cases,  three  or  four  times  daily  in 
those  which  are  less  urgent ;  salicine,  in  doses  of  three  to  five  grains 
three  times  a  day,  recommended  by  Tyler  Smith  ;  oxalate  of  cerium, 
in  the  form  of  pill,  of  which  three  to  five  grains  may  be  given  three 
times  a  day — a  remedy  strongly  advocated  by  Sir  James  Simpson, 
and  which  occasionally  is  of  undoubted  service,  but  more  often  fails ; 
the  compound  pyroxylic  spirit  of  the  London  Pharmacopoeia  in  doses 
of  five  minims  every  four  hours,  with  a  little  compound  tincture  of 
cardamoms,  a  drug  which  is  comparatively  little  known,  but  which 
occasionally  has  a  very  marked  and  beneficial  effect  in  checking- 
vomiting  ;  opiates  in  various  forms — which  sometimes  prove  useful, 
more  often  not — may  be  administered  either  by  the  mouth  or  in  pills 
containing  from  half  a  grain  to  a  grain  of  opium,  or  in  small  doses 
of  the  solution  of  the  bimeconate  of  morphia  or  of  Battley's  sedative 
solution,  or  subcutaneously,  a  mode  of  administration  which  is  much 
more  often  successful.  If  there  is  much  tenderness  about  the  epigas- 
trium, one  or  two  leeches  may  be  advantageously  applied,  or  one- 
third  of  a  grain  of  morphia  may  be  sprinkled  on  the  surface  of  a 
small  blister,  or  cloths  saturated  in  laudanum  may  be  kept  over  the 
pit  of  the  stomach.  In  many  cases  I  have  found  that  the  applica- 
tion of  a  spinal  ice-bag  to  the  cervical  vertebrae,  in  the  manner  re- 
commended by  Dr.  Chapman,  has  checked  the  vomiting  when  all 
drugs  have  failed.  The  ice  may  be  placed  in  one  of  Chapman's 
spinal  ice-bags,  and  applied  lor  ten  minutes  or  a  quarter  of  an  hour, 
twice  or  three  times  a  day.  It  invariably  produces  a  comforting 
sensation  of  warmth,  which  is  always  agreeable  to  the  patient.  Ice 
may  be  given  to  suck  ad  libitum,  and  is  very  useful ;  while,  if  there 
be  much  exhaustion,  small  quantities  of  iced  champagne  may  also 
be  given  from  time  to  time. 

Local  Treatment. — Inasmuch  as  the  vomiting  unquestionably  has 
its  origin  in  the  uterus,  it  is  only  natural  that  practitioners  should 
endeavor  to  check  it  by  remedies  calculated  to  relieve  the  irritability 
of  that  organ.  Thus  morphia  in  the  form  of  pessaries  per  vaginam, 
or  belladonna  applied  to  the  cervix,  has  been  recommended,  and — 
the  former  especially — are  often  of  undoubted  service.  A  pessary 
containing  one-third  to  half  a  grain  of  morphia  may  be  introduced 
night  and  morning,  without  interfering  with  other  methods  of  treat- 
ment. Dr.  Henry  Bennet  directs  especial  attention  to  the  cervix, 
which,  he  says,  is  almost  always  congested  and  inflamed,  and  covered 
with  granular  erosions.  This  condition  he  recommends  to  be  treated 
by  the  application  of  nitrate  of  silver  through  the  speculum.  Dr. 
Clay,  of  Manchester,  corroborates  this  view,  and  strongly  advocates, 
.especially  when  vomiting  continues  in  the  latter  months,  that  one  or 
two  leeches  should  be  applied  to  the  cervix.  Exception  may  fairly 
:be  taken  to  both  these  methods  of  treatment  as  being  somewhat 
hazardous,  unless  other  means  have  been  tried  and  failed.  I  have 
'little  doubt,  however,  that,  in  many  cases,  a  state  of  uterine  con- 
gestion is  an  important  factor  in  keeping  up  the  unduly  irritable 
.condition  of  the  uterine  fibres,  and  an  endeavor  should  always  be 


DISEASES    OF    PREGNANCY.  187 

made  to  lessen  it  by  insisting  on  absolute  rest  in  the  recumbent  pos- 
ture. Of  the  importance  of  this  precaution  in  obstinate  cases  there 
can  be  no  question.  Dr.  Chapman,  of  Norwich,  strongly  recommends 
dilation  of  the  cervix  by  the  finger,  and  states  that  he  has  found  it 
very  serviceable  in  checking  nausea.  It  is  obvious  that  this  treat- 
ment must  be  adopted  with  great  caution,  as,  roughly  performed,  it 
might  lead  to  the  production  of  abortion.  Dr.  Hewitt's  views  as  to 
the  dependence  of  sickness  on  flexions  of  the  uterus  have  already 
been  adverted  to,  and  reasons  have  been  given  for  doubting  the 
general  correctness  of  his  theory.  It  is  quite  likely,  however,  that 
well-marked  displacements  of  the  uterus,  either  forwards  or  back- 
wards, may  serve  to  intensify  the  irritability  of  the  organ.  Cazeaux 
mentions  an  obstinate  case  immediately  cured  by  replacing  a  retro- 
verted  uterus.  A  careful  vaginal  examination  should,  therefore,  be 
instituted  in  all  intractable  cases,  and  if  distinct  displacement  be  de- 
tected, an  endeavor  should  be  made  to  support  the  uterus  in  its 
normal  axis.  If  retroverted,  a  Hodge's  pessary  may  be  safely  em- 
ployed ;  if  anteverted,  a  small  air-ball  pessary,  as  recommended  by 
Hewitt,  should  be  inserted.  I  believe,  however,  that  such  displace- 
ments are  the  exception  rather  than  the  rule  in  cases  of  severe 
sickness. 

The  importance  of  promoting  nutrition  by  every  means  in  our 
power  should  always  be  borne  in  mind.  The  exhaustion  produced 
by  want  of  food  soon  increases  the  irritable  state  of  the  nervous 
system,  and,  if  the  stomach,  will  not  retain  anything,  we  can  only 
combat  it  by  occasional  nutrient  enemata  of  strong  beef  tea,  yolk  of 
egg,  and  the  like.  ' 

The  Production  of  Artificial  Abortion. — Finally,  in  the  worst  class 
of  cases,  when  all  treatment  has  failed,  and  when  the  patient  has 
fallen  into  the  condition  of  extreme  prostration  already  described,  we 
may  be  driven  to  consider  the  necessity  of  producing  abortion.  For- 
tunately cases  justifying  this  extreme  resource  are  of  great  rarity, 
but  nevertheless  there  is  abundant  evidence  that,  every  now  and  then, 
women  do  die  from  uncontrollable  vomiting,  whose  lives  might  have 
been  saved  had  the  pregnancy  been  brought  to  an  end.  The  value 
of  artificial  abortion  has  been  abundantly  proved.  Indeed,  it  is  re- 
markable how  rapidly  the  serious  symptoms  disappear  when  the 
uterus  is  emptied,  and  the  tension  of  the  uterine  fibres  lessened.  It 
has  fortunately  but  rarely  fallen  to  my  lot  to  have  to  perform  this 
operation  for  intractable  vomiting.  In  one  such  case  the  patient  was 
reduced  to  a  state  of  the  utmost  prostration,  having  kept  hardly  any 
food  on  her  stomach  for  many  weeks,  and  when  I  first  saw  her  she 
was  lying  in  a  state  of  low  muttering  delirium.  Within  a  few  hours 
after  abortion  was  induced  all  the  threatening  symptoms  had  disap- 
peared, the  vomiting  had  entirely  ceased,  and  she  was  next  day  able 
to  retain  and  absorb  all  that  was  given  to  her.  The  value  of  the 
operation,  therefore,  I  believe  to  be  undoubted.  Where  it  has  failed, 
it  seems  to  have  been  on  account  of  undue  delay.  Owing  to  the 
natural  repugnance  which  all  must  feel  towards  this  plan,  it  has  gene- 
rally been  postponed  until  the  patient  has  been  too  exhausted  to  rally. 


188  PREGNANCY. 

If,  therefore,  it  is  done  at  all,  it  should  be  before  prostration  has  ad- 
vanced so  far  as  to  render  the  operation  useless.  In  these  cases  the 
obvious  indication  is  to  lessen  the  tension  of  the  uterus  at  once,  and 
therefore  the  membranes  should  be  punctured  by  the  uterine  sound, 
so  as  to  let  the  liquor  amnii  drain  away,  and  this  may  of  itself  be 
sufficient  to  accomplish  the  desired  effect.  It  is  almost  needless  to 
add,  that  no  one  would  be  justified  in  resorting  to  this  expedient 
without  having  his  opinion  fortified  by  consultation  with  a  fellow- 
practitioner. 

Other  disorders  of  the  digestive  system  may  give  rise  to  considerable 
discomfort,  but  not  to  the  serious  peril  attending  obstinate  vomiting. 
Amongst  them  are  loss  of  appetite,  acidity  and  heartburn,  flatulent 
distension,  and  sometimes  a  capricious  appetite,  which  assumes  the 
form  of  longing  for  strange  and  even  disgusting  articles  of  diet.  As- 
sociated with  these  conditions  there  is  generally  derangement  of  the 
whole  intestinal  tract,  indicated  by  furred  tongue  and  sluggish  bowels, 
and  they  are  best  treated  by  remedies  calculated  to  restore  a  healthy 
condition  of  the  digestive  organs,  such  as  a  light  easily  digested  diet, 
mineral  acids,  vegetable  bitters,  occasional  aperients,  bismuth  and 
soda,  and  pepsiue.  The  indications  for  treatment  are  not  different 
from  those  which  accompany  the  same  symptoms  in  the  non-pregnant 
state. 

Diarrhoea  is  an  occasional  accompaniment  of  pregnancy,  often  de- 
pending on  errors  of  diet.  When  excessive  and  continuous  it  has  a 
decided  tendency  to  induce  uterine  contractions,  and  I  have  frequently 
observed  premature  labor  to  follow  a  sharp  attack  of  diarrhoea.  It 
should,  therefore,  not  be  neglected ;  and,  if  at  all  excessive,  should 
be  checked  by  the  usual  means,  such  as  chalk  mixture  with  aromatic 
confection,  and  small  doses  of  laudanum  or  chlorodyne.  The  possi- 
bility of  apparent  diarrhoea  being  associated  with  actual  constipation, 
the  fluid  matter  finding  its  way  past  the  solid  materials  blocking  up 
the  intestines,  should  be  borne  in  mind. 

Constipation  is  much  more  common,  and  is  indeed  a  very  general 
accompaniment  of  pregnancy,  even  in  women  who  do  not  suffer  from 
it  at  other  times.  It  partly  depends  on  the  mechanical  interference 
of  the  gravid  uterus  with  the  proper  movements  of  the  intestines, 
and  partly  on  defective  innervation  of  the  bowels  resulting  from  the 
altered  state  of  the  blood.  The  first  indication  will  be  to  remedy 
this  defect  by  appropriate  diet,  such  as  fresh  fruits,  brown  bread,  oat- 
meal porridge,  etc.  Some  medicinal  treatment  will  also  be  necessary, 
and,  in  selecting  the  drugs  to  be  used,  care  should  be  taken  to  choose 
such  as  are  mild  and  unirritating  in  their  action,  and  tend  to  improve 
the  tone  of  the  muscular  coats  of  the  intestine.  A  small  quantity 
of  aperient  mineral  water  in  the  early  morning,  such  as  the  Hunyadi, 
Frederickshalle,  or  Pullna  water,  often  answers  very  well ;  or  an  oc- 
casional dose  of  the  confection  of  sulphur;  or  a  pill  containing  three 
or  four  grains  of  the  extract  of  colocynth,  with  a  quarter  of  a  grain 
of  the  extract  of  nux  vomica,  and  a  grain  of  extract  of  hyoscyamus 
at  bed  time;  or  a  teaspoonful  of  the  compound  liquorice  powder  in 
milk  at  bed  time.  Constipation  is  also  sometimes  effectually  combated 


DISEASES    OF    PREGNANCY.  189 

by  administering,  twice  daily,  a  pill  containing  a  couple  of  grains  of 
the  inspissated  ox-gall,  with  a  quarter  of  a  grain  of  extract  of  bella- 
donna. Enemata  of  soap  and  water  are  often  very  useful,  and  have 
the  advantage  of  not  disturbing  the  digestion.  In  the  latter  months 
of  pregnancy,  especially  in  the  few  weeks  preceding  delivery,  the 
irritation  produced  by  the  collection  of  hardened  feces  in  the  bowel 
is  a  not  infrequent  cause  of  the  annoying  false  pains  which  then  so 
commonly  trouble  the  patient.  In  order  to  relieve  them,  it  will  be 
necessary  to  empty  the  bowels  thoroughly  by  an  aperient,  such  as  a 
good  dose  of  castor-oil,  to  which  fifteen  or  twenty  minims  of  laudanum 
may  be  advantageously  added.  Should  the  rectum  become  loaded 
with  scybalous  masses,  it  may  be  necessary  to  break  down  and  re- 
move them  by  mechanical  means,  provided  we  are  unable  to  effect 
this  by  copious  enemata. 

Hemorrhoids. — The  loaded  state  of  the  rectum  so  common  in  preg- 
nancy, combined  with  the  mechanical  effect  of  the  pressure  of  the 
gravid  uterus  on  the  hemorrhoidal  veins,  often  produces  very  trou- 
blesome symptoms  from  piles.  In  such  cases  a  regular  and  gentle 
evacuation  of  the  bowels  should  be  secured  daily,  so  as  to  lessen  as 
much  as  possible  the  congestion  of  the  veins.  Any  of  the  aperients 
already  mentioned,  especially  the  sulphur  electuary,  may  be  used. 
Dr.  Fordyce  Barker1  insists  that,  contrary  to  the  usual  impression, 
one  of  the  best  remedies  for  this  purpose  is  a  pill  containing  a  grain 
or  a  grain  and  a  half  of  powdered  aloes,  with  a  quarter  of  a  grain  of 
extract  of  nux  vomica,  and  that  castor  oil  is  distinctly  prejudicial, 
and  apt  to  increase  the  symptoms.  I  have  certainly  found  it  answer 
well  in  several  cases.  When  the  piles  are  tender  and  swollen,  they 
should  be  freely  covered  with  an  ointment  consisting  of  four  grains 
of  muriate  of  morphia  to  an  ounce  of  simple  ointment,  or  with  the 
Ung.  Gallse  c.  opio  [an  addition  of  3j  of  ext.  of  stramonium  to  3j  of 
this  ointment,  will  be  found  valuable. — ED.]  of  the  Pharmacopoeia ; 
and,  if  protruded,  an  attempt  should  be  made  to  push  them  gently 
above  the  sphincter,  by  which  they  are  often  unduly  constricted. 
Eelief  may  also  be  obtained  by  frequent  hot  fomentations,  and  some- 
times, when  the  piles  are  much  swollen,  it  will  be  found  useful  to 
puncture  them,  so  as  to  lessen  the  congestion,  before  any  attempt  at 
reduction  is  made. 

Ptyalism. — A  profuse  discharge  from  the  salivary  glands  is  an 
occasional  distressing  accompaniment  of  pregnancy.  It  is  generally 
confined  to  the  early  months,  but  it  occasionally  continues  during  the 
whole  period  of  gestation,  and  resists  all  treatment,  only  ceasing 
when  delivery  is  over.  Under  such  circumstances  the  discharge  of 
saliva  is  sometimes  enormous,  amounting  to  several  quarts  a  day, 
and  the  distress  and  annoyance  to  the  patient  are  very  great.  In  one 
case  under  my  care  the  saliva  poured  from  the  mouth  all  day  long, 
and  for  several  months  the  patient  sat  with  a  basin  constantly  by  her 
side,  incessantly  emptying  her  mouth,  until  she  was  reduced  to  a 
condition  giving  rise  to  really  serious  anxiety.  This  profuse  saliva- 

1  The  Puerperal  Diseases,  p   33. 


190  PREGNANCY. 

tion  is,  no  doubt,  a  purely  nervous  disorder,  and  not  readily  con- 
trolled by  remedies.  Astringent  gargles,  containing  tannin  and 
chlorate  of  potass,  frequent  sucking  of  ice,  or  of  tannin  lozenges,  in- 
halation of  turpentine  and  creasote,  counter-irritation  over  the  sali- 
vary glands  by  blisters  or  iodine,  the  bromides,  opium  internally, 
may  all  be  tried  in  turn,  but  none  of  them  can  be  depended  on  with 
any  degree  of  confidence. 

Toothache  and  Caries  of  the  Teeth. — Severe  dental  neuralgia  is  also 
a  frequent  accompaniment  of  pregnancy,  especially  in  the  early 
months.  When  purely  neuralgic,  quinine  in  tolerably  large  doses  is 
the  best  remedy  at  our  disposal ;  but  not  infrequently,  it  depends  on 
actual  caries  of  the  teeth,  and  attention  should  always  be  paid  to  the 
condition  of  the  teeth  when  facial  neuralgia  exists.  There  is  no 
doubt  that  pregnancy  predisposes  to  caries,  and  the  observation  of 
this  fact  has  given  rise  to  the  old  proverb,  "  for  every  child  a  tooth." 
Mr.  Oakley  Coles,  in  an  interesting  paper1  on  the  condition  of  the 
mouth  and  teeth  during  pregnancy,  refers  the  prevalence  of  caries  to 
the  co-existence  of  acid  dyspepsia,  causing  acidity  of  the  oral  secre- 
tions. There  is  much  unreasonable  dread  amongst  practitioners  as 
to  interfering  with  the  teeth  during  pregnancy,  and  some  recommend 
that  all  operations,  even  stopping,  should  be  postponed  until  after 
delivery.  It  seems  to  me  certain  that  the  suffering  of  severe  tooth- 
ache is  likely  to  give  rise  to  far  more  severe  irritation  than  the  opera- 
tion required  for  its  relief,  and  I  have  frequently  seen  badly  decayed 
teeth  extracted  during  pregnancy,  and  with  only  a  beneficial  result. 
[We  have  had  nitrous  oxide  administered  and  teeth  extracted  with- 
out difficulty,  or  any  apparent  risk. — ED.] 

Affections  of  the  Respiratory  Organs. — Amongst  the  derangements 
of  the  respiratory  organs,  one  of  the  most  common  is  spasmodic 
cough,  which  is  often  excessively  troublesome.  Like  many  other  of 
the  sympathetic  derangements  accompanying  gestation,  it  is  purely 
nervous  in  character,  and  is  unaccompanied  by  elevated  temperature, 
quickened  pulse,  or  any  distinct  auscultatory  phenomena.  In  char- 
acter it  is  not  unlike  whooping-cough.  The  treatment  must  obviously 
be  guided  by  the  character  of  the  cough.  Expectorants  are  not  likely 
to  be  of  service,  while  benefit  may  be  derived  from  some  of  the  anti- 
spasmodic  class  of  drugs,  such  as  belladonna,  hydrocyanic  acid,  opi- 
ates, or  bromide  of  potassium.  Such  remedies  may  be  tried  in  suc- 
cession, but  will  often  be  found  to  be  of  little  value  in  arresting  the 
cough.  Dyspnoea  may  also  be  nervous  in  character,  and  sometimes 
symptoms,  not  unlike  those  of  spasmodic  asthma,  are  produced. 
Like  the  other  sympathetic  disorders,  it,  as  well  as  nervous  cough, 
is  most  frequently  observed  during  the  early  months.  There  is  an- 
other form  of  dyspnoea,  not  uncommonly  met  with,  which  is  the  me- 
chanical result  of  the  interference  with  the  action  of  the  diaphragm 
and  lungs  by  the  pressure  of  the  enlarged  uterus.  Hence  this  is 
most  generally  troublesome  in  the  latter  mouths,  and  continues  unre- 
lieved until  delivery,  or  until  the  sinking  of  the  uterine  tumor  which 

1  Trans,  of  the  Odontological  Society. 


DISEASES    OF    PREGNANCY.  191 

immediately  precedes  it.  Beyond  taking  care  that  the  pressure  is 
not  increased  by  tight  lacing,  or  injudicious  arrangement  of  the 
clothes,  there  is  little  that  can  be  clone  to  relieve  this  form  of  breath- 
lessness.  [Anoint  the  abdomen  of  the  patient,  and  let  her  sleep  on 
an  inclined  plane  with  a  pillow  under  her  thighs  and  knees. — ED.] 

Palpitation,  like  dyspnoea,  may  be  due  either  to  sympathetic  dis- 
turbance, or  to  mechanical  interference  with  the  proper  action  of  the 
heart.  "When  occurring  in  weakly  women  it  may  be  referred  to  the 
functional  derangements  which  accompany  the  chlorotic  condition 
of  the  blood  often  associated  with  pregnancy,  and  is  then  best  reme- 
died by  a  general  tonic  regimen,  and  the  administration  of  ferruginous 
preparations.  At  other  times  anti-spasmodic  remedies  may  be  indi- 
cated, but  it  is  seldom  sufficiently  serious  to  call  for  much  special 
treatment. 

Syncope. — Attacks  of  fainting  are  not  rare,  especially  in  delicate 
women  of  highly-developed  nervous  temperament,  and  are  perhaps 
most  common  at  or  about  the  period  of  quickening,  although  some- 
times lasting  through  the  whole  pregnancy.  In  most  cases  these 
attacks  cannot  be  classed  as  cardiac,  but  are  more  probably  nervous 
in  character,  and  they  are  rarely  associated  with  complete  abolition 
of  consciousness.  They  rather,  therefore,  resemble  the  condition 
described  by  the  older  authors  as  lypothemia.  The  patient  lies  in  a 
semi-unconscious  condition  with  a  feeble  pulse  and  widely-dilated 
pupils,  and  this  state  lasts  for  varying  periods,  from  a  few  minutes 
to  half  an  hour  or  more.  In  one  very  troublesome  case  under  my 
care  they  often  recurred  as  frequently  as  three  or  four  times  a  day. 
I  have  observed  that  they  rarely  occur  when  the  more  common  sym- 
pathetic phenomena  of  pregnancy,  especially  vomiting,  are  present. 
Sometimes  they  terminate  with  the  ordinary  symptoms  of  hysteria 
such  as  sobbing.  The  treatment  should  consist  during  the  attack  in 
the  administration  of  diffusible  stimulants,  such  as  ether,  sal- volatile, 
and  valerian,  the  patient  being  placed  in  the  recumbent  position  with 
the  head  low.  If  frequently  repeated  it  is  unadvisable  to  attempt  to 
rally  the  patient  by  the  too  free  administration  of  stimulants.  In  the 
intervals  a  generally  tonic  regimen,  and  the  administration  of  ferru- 
ginous remedies,  are  indicated.  If  they  recur  with  great  frequency 
the  daily  application  of  the  spinal  ice-bag  has  proved  of  much  service. 

Extreme  Anaemia  and  Chlorosis. — In  connection  with  disorders  of 
the  circulatory  system  may  be  noticed  those  which  depend  on  the 
state  of  the  blood.  The  altered  condition  of  the  blood,  which  has. 
already  been  described  as  a  physiological  accompaniment  of  pregnancy 
(p.  130),  is  sometimes  carried  to  an  extent  which  may  fairly  be  called', 
morbid;  and,  either  on  account  of  the  deficiency  of  blood-corpuscles, 
or  from  the  increase  in  its  watery  constituents,  a  state  of  extreme- 
anaemia  and  chlorosis  may  be  developed.  This  may  be  sometimes, 
carried  to  a  very  serious  extent.  Thus  Gusserow1  records  five  cases 
in  which  nothing  but  excessive  anaemia  could  be  detected,  all  of  which 
ended  fatally.  Generally  when  such  symptoms  have  been  carried  to.. 

1  Arch.  f.  Gyn.  ii.  2,  1871. 


192  PREGNANCY. 

an  extreme  extent,  the  patient  has  been  in  a  state  of  chlorosis  before 
pregnancy.  The  treatment  must,  of  course,  be  calculated  to  improve 
the  general  nutrition,  and  enrich  the  impoverished  blood ;  a  light 
and  easily  assimilated  diet,  milk,  eggs,  beef-tea,  and  animal  food — if 
it  can  be  taken — attention  to  the  proper  action  of  the  bowels,  a  due 
amount  of  stimulants,  and  abundance  of  fresh  air,  will  be  the  chief 
indications  in  the  general  management  of  the  case.  Medicinally,  fer- 
ruginous preparations  will  be  required.  Some  practitioners  object, 
apparently  without  sufficient  reason,  to  the  administration  of  iron 
during  pregnancy,  as  liable  to  promote  abortion.  This  unfounded 
prejudice  may  probably  be  traced  to  the  supposed  emmenagogue  prop- 
erties of  the  preparations  of  iron  ;  but,  if  the  general  condition  of  the 
patient  indicate  such  medication,  they  may  be  administered  without 
any  fear  Preparations  of  phosphorous,  such  as  the  phosphide  of 
zinc,  or  free  phosphorous  in  capsules,  also  promise  favorably,  and 
are  well  worthy  of  trial. 

(Edema  associated  with  Hydrsemia. — Some  of  the  more  aggravated 
cases  are  associated  with  a  considerable  amount  of  serous  effusion 
into  the  cellular  tissue,  generally  limited  to  the  lower  extremities, 
but  occasionally  extending  to  the  arms,  face,  and  neck,  and  even 
producing  ascites  and  pleuritic  effusion.  Under  the  latter  circum- 
stances this  complication  is.  of  course,  of  great  gravity,  and  it  is  said 
that  after  delivery  the  disappearance  of  the  serous  effusion  may  be 
accompanied  by  metastasis  of  a  fatal  character  to  the  lungs  or  the 
nervous  centres.  This  form  of  oedema  must  be  distinguished  from 
the  slight  cedematous  swelling  of  the  feet  and  legs  so  commonly  ob- 
served as  a  mechanical  result  of  the  pressure  of  the  gravid  uterus, 
and  also  from  those  cases  of  oedema  associated  with  albuminuria. 
The  treatment  must  be  directed  to  the  cause,  while  the  disappearance 
of  the  effusion  may  be  promoted  by  the  administration  of  diuretic 
drinks,  the  occasional  use  of  saline  aperients,  and  rest  in  the  horizon- 
tal position. 

Albuminuria. — The  existence  of  albumen  in  the  urine  of  pregnant 
women  has  for  many  years  attracted  the  attention  of  obstetricians, 
and  it  is  now  well  known  to  be  associated,  in  ways  still  imperfectly 
understood,  with  many  important  puerperal  diseases.  Its  presence 
in  most  cases  of  puerperal  eclampsia  was  long  ago  pointed  out  by 
Lever  in  this  country  and  Eayer  in  France,  and  its  association  with 
this  disease  gave  rise  to  the  theory  of  the  dependence  of  the  convul- 
sion on  uraemia,  which  is  still  generally  entertained.  It  has  been 
shown  of  late  years,  especially  by  Braxton  Hicks,  that  this  associa- 
tion is  by  no  means  so  universal  as  was  supposed ;  or  rather  that,  in 
some  cases,  the  albuminuria  follows  and  does  not  precede  the  convul- 
.sions,  of  which  it  might  therefore  be  supposed  to  be  the  consequence 
rather  than  the  cause ;  so  that  further  investigations  as  to  these  par- 
ticular points  are  still  required.  Modern  researches  have  shown  that 
there  is  an  intimate  connection  between  many  other  affections  and 
albuminuria ;  as,  for  example,  certain  forms  of  paralysis,  either  of 
special  nerves,  as  puerperal  amaurosis,  or  of  the  spinal  system ; 
cephalalgia  and  dizziness ;  puerperal  mania ;  and  possibly  hemor- 


DISEASES    OF    PREGNANCY.  193 

rhage.  It  cannot,  therefore,  be  doubted  that  alburninuria  in  the 
pregnant  woman  is  liable,  at  any  rate,  to  be  associated  with  grave 
disease,  although  the  present  state  of  our  knowledge  does  not  enable 
us  to  define  very  distinctly  its  precise  mode  of  action. 

Causes  of  Puerperal  Alburninuria. — As  the  presence  of  albumen 
in  the  urine  of  pregnant  women  is  far  from  a  rare  phenomenon — 
being  met  with,  according  to  the  researches  of  Blot  and  Litzrnan,  in 
20  per  cent,  of  pregnant  women — and  as,  in  the  large  majority  of 
these  cases,  it  rapidly  disappears  after  delivery,  it  is  obvious  that  its 
presence  must,  in  a  large  proportion  of  cases,  depend  on  temporary 
causes,  and  has  not  always  the  same  serious  importance  as  in  the 
non-pregnant  state.  This  is  further  proved  by  the  undoubted  fact 
that  albumen,  rapidly  disappearing  after  delivery,  is  often  found  in 
urine  of  pregnant  women  who  go  to  term,  and  pass  through  labor 
without  any  unfavorable  symptoms. 

Pressure  by  the  Gravid  Uterus. — The  obvious  fact  that  in  pregnancy 
the  vessels  supplying  the  kidneys. are  subjected  to  mechanical  pres- 
sure from  the  gravid  uterus,  and  that  congestion  of  the  venous  circu- 
lation of  those  viscera  must  necessarily  exist  to  a  greater  or  less 
degree,  suggests  that  here  we  may  find  an  explanation  of  the  frequent 
occurrence  of  alburninuria.  This  view  is  further  strengthened  by  the 
fact  that  the  albumen  rarely  appears  until  after  the  fifth  month,  and, 
therefore,  not  until  the  uterus  has  attained  a  considerable  size;  and 
also  that  it  is  comparatively  more  frequently  met  with  in  primiparse, 
in  whom  the  resistance  of  the  abdominal  parietes,  and  consequent 
pressure,  must  be  greater  than  in  women  who  have  already  borne 
children.  It  is,  indeed,  probable  that  pressure  and  consequent  venous 
congestion  of  the  kidneys  have  an  important  influence  in  its  produc- 
tion; but  there  must  be,  as  a  rule,  some  other  factor  in  operation, 
since  an  equal  or  even  greater  amount  of  pressure  is  often  exerted 
by  ovarian  and  fibroid  tumors,  without  any  such  consequences. 

Altered  State  of  the  Blood. — This  is  probably  to  be  found  in  the 
altered  condition  of  the  blood,  which,  on  account  of  the  unusual  call 
for  nutritive  supply  on  the  part  of  the  foetus,  contains  an  excess  of 
albuminous  material.  Hence  we  have  two  factors  always  at  work  in 
the  pregnant  woman,  both  predisposing  to  the  escape  of  albumen, 
viz.,  a  turgid  state  of  the  renal  venous  system,  and  a  super-albumi- 
nous condition  of  the  blood.  But  in  the  large  majority  of  cases, 
although  these  conditions  are  present,  no  alburninuria  exists,  and  they 
must,  therefore,  be  looked  upon  as  predisposing  causes,  to  which  some 
other  is  added  before  the  albumen  escapes  from  the  vessels.  What 
this  is  generally  escapes  our  observation,  but  probably  any  condition 
producing  sudden  hyperaemia  of  the  kidneys,  and  giving  rise  to  a 
state  analogous  to  the  first  stage  of  Bright's  disease — such,  for  ex- 
ample, as  sudden  exposure  to  cold  and  impeded  cutaneous  action — 
may  be  sufficient  to  set  a  light  to  the  match  already  prepared  by  the 
existence  of  pregnancy.  In  addition  to  these  temporary  causes  it 
must  not  be  forgotten  that  pregnancy  may  supervene  in  a  patient 
already  suffering  from  Bright's  disease,  when  of  course  the  albumen 
will  exist  in  the  urine  from  the  commencement  of  gestation. 


194  PREGNANCY. 

The  Effects  of  Puerperal  Albuminuria. — The  various  diseases  asso- 
ciated with  the  presence  of  albumen  in  the  urine  will  require  sepa- 
rate consideration.  Some  of  these,  especially  puerperal  eclampsia,  are 
amongst  the  most  dangerous  complications  of  pregnancy.  Others,  such 
as  paralysis,  cephalalgia,  dizziness,  may  also  be  of  considerable  gravity. 
The  precise  mode  of  their  production,  and  whether  they  can  be  traced, 
as  is  generally  believed,  to  the  retention  of  urinary  elements  in  the 
blood,  either  urea  or  free  carbonate  of  ammonia  produced  by  its  de- 
composition, or  whether  the  two  are  only  common  results  of  some 
undetermined  cause,  Avill  be  considered  when  we  come  to  discuss 
puerperal  convulsions.  Whatever  view  may  ultimately  be  taken  on 
these  points,  it  is  sufficiently  obvious  that  albuminuria  in  a  pregnant 
woman  must  constantly  be  a  source  of  much  anxiety,  and  must  induce 
us  to  look  forward  with  considerable  apprehension  to  the  termination 
of  the  case. 

Prognosis. — We  are  scarcely  in  possession  of  a  sufficiently  large 
number  of  observations  to  justify  any  very  accurate  conclusions  as 
to  the  risk  attending  albuminuria  during  pregnancy,  but  it  is  certainly 
by  no  means  slight.  One  source  of  danger  is  that  the  morbid  state 
of  the  kidneys  may  become  permanent,  and  may  lead  to  the  estab- 
lishment of  Bright's  disease  after  the  pregnancy  is  over.  Goubeyre 
estimated  that  49  per  cent,  of  primiparse  who  have  albuminuria,  and 
who  escape  eclampsia,  die  from  morbid  conditions  traceable  to  the 
albuminuria.  This  conclusion  is  probably  much  exaggerated,  but  if 
it  even  approximates  to  the  truth,  the  danger  must  be  very  great. 

Tendency  to  produce  Abortion. — Besides  the  ultimate  risk  to  the 
mother,  albuminuria  strongly  predisposes  to  abortion,  no  doubt  on 
account  of  the  imperfect  nutrition  of  the  foetus  by  blood  impoverished 
by  the  drain  of  albuminous  materials  through  the  kidneys.  This 
fact  has  been  observed  by  many  writers.  A  good  illustration  of  it 
is  given  by  Tanner,1  who  states  that  four  out  of  seven  women  he  at- 
tended suffering  from  Bright's  disease  during  pregnancy,  aborted,  one 
of  them  three  times  in  succession. 

Symptoms. — The  symptoms  accompanying  albuminuria  in  preg- 
nancy are  by  no  means  ujiiform  or  constantly  present.  That  which 
most  frequently  causes  suspicion  is  the  anasarca — -not  only  the  oede- 
matous  swelling  of  the  lower  limbs  which  is  so  common  a  consequence 
of  the  pressure'  of  the  gravid  uterus,  but  also  of  the  face  and  upper 
extremities.  Any  puffmess  or  infiltration  about  the  face,  or  any 
oedema  about  the  hands  or  arms,  should  always  give  rise  to  suspicion, 
and  lead  to  a  careful  examination  of  the  urine.  Sometimes  this  is 
carried  to  an  exaggerated  degree,  so  that  there  is  anasarca  of  the 
whole  body. 

Anomalous  nervous  symptoms — such  as  headache,  transient  dizzi- 
ness, dimness  of  vision,  spots  before  the  eyes,  inability  to  see  objects 
distinctly,  sickness  in  women  not  at  other  times  suffering  from 
nausea,  sleeplessness,  irritability  of  temper — are  also  often  met  with, 
sometimes  to  a  slight  degree,  at  others  very  strongly  developed,  and 

1  Signs  and  Diseases  of  Pregnancy,  p.  428. 


DISEASES    OF    PREGNANCY.  195 

should  always  arouse  suspicion.  Indeed,  knoAving  as  AVC  do  that 
many  morbid  states  may  be  associated  with  albuminuria,  AVC  should 
make  a  point  of  carefully  examining  the  urine  of  all  patients  in 
whom  any  unusual  morbid  phenomena  shoAV  themselves  during 
pregnancy. 

Character  of  the  Urine. — The  condition  of  the  urine  varies  con- 
siderably, but  it  is  generally  scanty  and  highly  colored,  and,  in 
addition  to  the  albumen,  especially  in  cases  in  Avhich  the  albuminuria 
has  existed  for  some  time,  we  may  find  epithelium  cells,  tube  casts, 
arid  occasionally  blood  corpuscles. 

Treatment. — The  treatment  must  be  based  on  what  has  been  said 
as  to  the  causes  of  the  albuminuria.  Of  course  it  is  out  of  our  power 
to  remove  the  pressure  of  the  gravid  uterus,  except  by  inducing 
labor ;  but  its  effects  may  at  least  be  lessened  by  remedies  tending 
to  promote  an  increased  secretion  of  urine,  and  thus  diminishing  the 
congestion  of  the  renal  vessels.  The  administration  of  saline  diure- 
tics, such  as  the  acetate  of  potash,  or  bitartrate  of  potash,  the  latter 
being  given  in  the  form  of  the  well-known  imperial  drink,  will  best 
ansAver  this  indication.  The  action  of  the  bowels  may  be  solicited 
by  purgatives  producing  Avatery  motions,  such  as  occasional  doses  of 
the  compound  jalap  pOAvder.  Dry  cupping  over  the  loins,  frequently 
repeated,  has  a  beneficial  effect  in  lessening  the  renal  hyperaemia. 
The  action  of  the  skin  should  also  be  promoted  by  the  use  of  the 
vapor  bath,  and  Avith  this  view  the  Turkish  bath  may  be  employed 
with  great  benefit  and  perfect  safety.  The  next  indication  is  to 
improve  the  condition  of  the  blood  by  appropriate  diet  and  medica- 
tion. A  very  light  and  easily  assimilated  diet  should  be  ordered,  of 
Avhich  milk  should  form  the  staple.  Tarnier1  has  recorded  several 
cases  in  which  a  purely  milk  diet  was  very  successful  in  removing 
albuminuria.  With  the  milk  we  may  allow  Avhite  of  egg,  or  a  little 
white  fish.  The  tincture  of  the  perchloride  of  iron  is  the  best  medi- 
cine we  can  give,  and  it  may  be  advantageously  combined  with  small 
doses  of  tincture  of  digitalis,  Avhich  acts  as  an  excellent  diuretic. 

Question  of  Inducing  Labor. — Finally,  in  obstinate  cases  we  shall 
have  to  consider  the  advisability  of  inducing  premature  labor.  The 
propriety  of  this  procedure  in  the  albuminuria  of  pregnancy  has  of 
late  years  been  much  discussed,  and  I  believe  that,  having  in  view 
the  undoubted  risks  which  attend  this  complication,  the  operation  is 
unquestionably  indicated,  and  is  perfectly  justifiable,  in  all  cases  at- 
tended with  symptoms  of  gravity.  It  is  not  easy  to  lay  down  any 
definite,  rules/ to  guide  our  decision;  but  I  should  not  hesitate  to 
adopt  this  resource  in  all  cases  in  which  the  quantity  of  albumen  is 
considerable  and  progressively  increasing,  and  in  which  treatment 
has  failed  to  lessen  the  amount ;  and,  above  all,  in  every  case  attended 
with  threatening  symptoms,  such  as  severe  headache,  dizziness,  or 
loss  of  sight.  The  risks  of  the  operation  are  infinitesimal  compared 
to  those  Avhich  the  patient  Avould  run  in  the  event  of  puerperal  con- 
vulsions supervening,  or  chronic  Bright's  disease  becoming  estab- 

1  Annal.  de  Gynec.,  Jan.  1876. 


196  PREGNANCY. 

lished.  As  the  operation  is  seldom  likely  to  be  indicated  until  the 
child  has  reached  a  viable  age,  and  as  the  albuminuria  places  the 
child's  life  in  danger,  we  are  quite  justified  in  considering  the  mother's 
safety  alone  in  determining  on  its  performance. 


CHAPTER  VIII. 

DISEASES  OF  PKEGNANCY  (CONTINUED). 

Disorders  of  the  Nervous  System. — There  are  many  disorders  of  the 
nervous  system  met  with  during  the  course  of  pregnancy.  Among 
the  most  common  are  morbid  irritability  of  temper,  or  a  state  of 
mental  despondency  and  dread  of  the  results  of  the  labor,  sometimes 
almost  amounting  to  insanity,  or  even  progressing  to  actual  mania. 
These  are  but  exaggerations  of  the  highly  susceptible  state  of  the 
nervous  system  generally  associated  with  gestation.  Want  of  sleep 
is  not  uncommon,  and,  if  carried  to  any  great  extent,  may  produce 
serious  trouble  from  the  irritability  and  exhaustion  it  produces.  In 
such  cases  we  should  endeavor  to  lessen  the  excitable  state  of  the 
nerves,  by  insisting  on  the  avoidance  of  late  hours,  over-much  society, 
exciting  amusements,  and  the  like  ;  while  it  may  be  essential  to  pro- 
mote sleep  by  the  administration  of  sedatives,  none  answering  so  well 
as  the  chloral  hydrate,  in  combination  with  large  doses  of  the  bro- 
mide of  potassium,  which  greatly  intensifies  its  hypnotic  effects. 
[Bromide  of  sodium,  since  its  reduction  in  price,  being  more  soluble, 
more  purely  saline,  more  active,  and  more  grateful  to  the  stomach, 
is  gradually  supplanting  in  a  measure  the  salt  of  potash. — ED.] 

Headaches  and  Neuralgia. — Severe  headaches  and  various  intense 
neuralgias  are  common.  Amongst  the  latter  the  most  frequently 
met  with  are  pain  in  the  breasts,  due  to  the  intimate  sympathetic 
connection  of  the  mammae  with  the  gravid  uterus ;  and  intense  inter- 
costal neuralgia,  which  a  careless  observer  might  mistake  for  pleu- 
ritic or  inflammatory  pain.  The  thermometer,  by  showing  that  there 
is  no  elevation  of  temperature,  would  prevent  such  a  mistake.  Neu- 
ralgia of  the  uterus  itself,  or  severe  pains  in  the  groin's  or  thighs — 
the  latter  being  probably  the  mechanical  results  of  dragging  on  the 
attachments  of  the  abdominal  muscles — are  also  far  from  uncommon. 
In  the  treatment  of  such  neuralgic  affections  attention  to  the  state  of 
the  general  health,  and  large  doses  of  quinine  and  ferruginous  pre- 
parations whenever  there  is  much  debility,  will  be  indicated.  Locally 
sedative  applications,  such  as  belladonna  and  chloroform  liniments ; 
friction  with  aconite  ointment  when  the  pain  is  limited  to  a  small 
space ;  and,  in  the  worst  cases,  the  subcutaneous  injection  of  mor- 
phia, will  be  called  for.  Those  pains  which  apparently  depend  on 


DISEASES    OF    PREGNANCY.  197 

mechanical  causes  may  often  be  best  relieved  by  lessening  the  trac- 
tion on  the  muscles,  by  wearing  a  well-made  elastic  belt  to  support 
the  uterus. 

Paralysis  depending  on  Pregnancy. — Among  the  most  interesting 
of  the  nervous  diseases  are  various  paralytic  affections.  Almost  all 
varieties  of  paralysis  have  been  observed,  such  as  paraplegia,  hemi- 
plegia  (complete  or  incomplete),  facial  paralysis,  and  paralysis  of  the 
nerves  of  special  sense,  giving  rise  to  amaurosis,  deafness,  and  loss  of 
taste.  Churchill  records  22  cases  of  paralysis  during  pregnancy, 
collected  by  him  from  various  sources.  A  large  number  have  also 
been  brought  together  by  Irnbert  Goubeyre,1  in  an  interesting  memoir 
on  the  subject,  and  others  are  recorded  by  Fordyce  Barker,  Joulin, 
and  other  authors ;  so  that  there  can  be  no  doubt  of  the  fact  that 
paralytic  affections  are  common  during  gestation.  In  the  large  pro- 
portion of  the  cases  recorded  the  paralyses  have  been  associated 
with  albuminuria,  and  are  doubtless  uroemic  in  origin.  Thus  in  19 
cases,  related  by  Goubeyre,  albuminuria  was  present  in  all.  The 
dependency  of  the  paralysis  on  a  transient  cause,  explains  the  fact 
that  in  the  large  majority  of  these  cases  the  paralysis  was  not  per- 
manent, but  disappeared  shortly  after  labor.  In  every  case  of  par- 
lysis,  whatever  be  its  nature,  special  attention  should  be  directed  to 
the  state  of  the  urine,  and,  should  it  be  found  to  be  albuminous, 
labor  should  be  at  once  induced.  This  is  clearly  the  proper  course 
to  pursue,  and  we  should  certainly  not  be  justified  in  running  the 
risk  that  must  attend  the  progress  of  a  case  in  which  so  formidable 
a  symptom  has  already  developed  itself.  When  the  cause  has  been 
removed,  the  effect  will  also  generally  rapidly  disappear,  and  the 
prognosis  is  therefore,  on  the  whole,  favorable.  Should  the  paralysis 
continue  after  delivery,  the  treatment  must  be  such  as  we  would 
adopt  in  the  non-pregnant  state ;  and  small  doses  of  strychnia,  along 
with  faradization  of  the  affected  limbs,  would  be  the  best  remedy  at 
our  disposal. 

Paralyses  which  are  not  Ursemic  in  their  Origin. — There  are,  how- 
ever, unquestionably  some  cases  of  puerperal  paralysis  which  are  not 
uraemic  in  their  origin,  and  the  nature  of  which  is  somewhat  obscure. 
Hemiplegia  may  doubtless  be  occasioned  by  cerebral  hemorrhage,  as 
in  the  non-pregnant  state.  Other  organic  causes  of  paralysis,  such 
as  cerebral  congestion,  or  embolism,  may,  now  and  again,  be  met 
with  during  pregnancy,  but  cases  of  this  kind  must  be  of  compara- 
tive rarity.  Other  cases  are  functional  in  their  origin.  Tarnier 
relates  a  case  of  hemiplegia  which  he  could  only  refer  to  extreme 
anaemia.  Some,  again,  may  be  hysterical.  Paraplegia  is  apparently 
more  frequently  unconnected  with  albuminuria  than  the  other  forms 
of  paralysis;  and  it  may  either  depend  on  pressure  of  the  gravid 
uterus  on  the  nerves  as  they  pass  through  the  pelvis,  or  on  reflex 
action,  as  is  sometimes  observed  in  connection  with  uterine  disease. 
When,  in  such  cases,  the  absence  of  albuminuria  is  ascertained  by 
freqiient  examination  of  the  urine,  there  is  obviously  not  the  same 

1  M6m.  de  1'Acacl.  de  M6d.,  1801. 


198  PREGNANCY. 

risk  to  the  patient  as  in  cases  depending  on  uraemia,  and  therefore  it 
may  be  justifiable  to  allow  pregnancy  to  go  on  to  term,  trusting  to 
subsequent  general  treatment  to  remove  the  paralytic  symptoms. 
As  the  loss  of  power  here  depends  on  a  transient  cause,  a  favorable 
prognosis  is  quite  justifiable.  [Partial  paralysis  of  one  lower  ex- 
tremity, generally  the  left,  sometimes  occurs,  from  pressure  of  the 
foetal  occiput,  and  may  continue  for  some  days  or  weeks,  with  a 
gradual  improvement,  after  parturition. — ED.] 

Chorea  is  not  infrequently  observed,  and  forms  a  serious  complica- 
tion. It  is  generally  met  with  in  young  women  of  delicate  health, 
and  in  the  first  pregnancy.  In  a  large  proportion  of  the  cases  the 
patient  has  already  suffered  from  the  disease  before  marriage.  On 
the  occurrence  of  pregnancy,  the  disposition  to  the  disease  again 
becomes  evoked,  and  choreic  movements  are  re-established.  This 
fact  may  be  explained  partly  by  the  susceptible  state  of  the  nervous 
system,  partly  by  the  impoverished  condition  of  the  blood. 

Prognosis. — That  chorea  is  a  dangerous  complication  of  pregnancy 
is  apparent  by  the  fact  that  out  of  56  cases  collected  by  Dr.  Barnes,1 
in  an  excellent  paper  on  the  subject,  no  less  than  17,  or  1  in  3,  proved 
fatal.  Nor  is  it  danger  to  life  alone  that  is  to  be  feared,  for  it  ap- 
pears certain  that  chorea  is  more  apt  to  leave  permanent  mental  dis- 
turbance when  it  occurs  during  pregnancy,  than  at  other  times.  It 
has  also  an  unquestionable  tendency  to  bring  on  abortion  or  prema- 
ture labor,  and  in  most  cases  the  life  of  the  child  is  sacrificed. 

Treatment. — The  treatment  of  chorea  during  pregnancy  does  not 
differ  from  that  of  the  disease  under  more  ordinary  circumstances ; 
and  our  chief  reliance  will  be  placed  on  such  drugs  as  the  liquor 
arsenicalis,  bromide  of  potassium,  and  iron.  In  the  severe  form  of 
the  disease,  the  incessant  movements,  and  the  weariness  and  loss  of 
sleep,  may  very  seriously  imperil  the  life  of  the  patient,  and  more 
prompt  and  radical  measures  will  be  indicated.  If,  in  spite  of  our 
remedies,  the  paroxysms  go  on  increasing  in  severity,  and  the 
patient's  strength  appears  to  be  exhausted,  our  only  resource  is  to 
remove  the  most  evident  cause  by  inducing  labor.  Generally  the 
symptoms  lessen  and  disappear  soon  after  this  is  done.  There  can 
be  no  question  that  the  operation  is  perfectly  justifiable,  and  may 
even  be  essential  under  such  circumstances.  It  should  be  borne  in 
mind  that  the  chorea  often  recurs  in  a  subsequent  pregnancy,  and 
extra  care  should  then  always  be  taken  to  prevent  its  development. 

Disorders  of  the  urinary  organs  are  of  frequent  occurrence.  Re- 
tention of  urine  may  be  met  with,  and  this  is  often  the  result  of  a 
retroverted  uterus.  The  treatment,  therefore,  must  then  be  directed 
to  the  removal  of  the  cause.  This  subject  will  be  more  particularly 
considered  when  we  come  to  discuss  that  form  of  displacement  (p. 
203) ;  but  we  may  here  point  out  that  retention  of  urine,  if  long  con- 
tinued, may  not  only  lead  to  much  distress,  but  to  actual  disease  of 
the  coats  of  the  bladder.  Several  cases  have  been  recorded  in  which 
cystitis,  resulting  from  urinary  retention  in  pregnancy,  eventually 

1  Obst.  Trans.,  vol.  x. 


DISEASES    OF    PREGNANCY.  199 

caused  the  exfoliation  of  the  entire  mucous  membrane  of  the  blad- 
der,1 which  was  cast  off,  sometimes  entire,  sometimes  in  shreds,  and 
occasionally  with  portions  of  the  muscular  coat  attached  to  it.  The 
possibility  of  this  formidable  accident  should  teach  us  to  be  careful 
not  to  allow  any  undue  retention  of  urine,  but,  by  a  timely  use  of 
the  catheter,  to  relieve  the  symptoms,  while  we,  at  the  same  time, 
endeavor  to  remove  the  cause. 

Irritability  of  the  bladder  is  of  frequent  occurrence.  In  the  early 
months  it  seems  to  be  the  consequence  of  sympathetic  irritation  of 
the  neck  of  the  bladder,  combined  with  pressure,  while  in  the  later 
months  it  is,  probably,  solely  produced  by  mechanical  causes.  When 
severe  it  leads  to  much  distress,  the  patient's  rest  being  broken  and 
disturbed  by  incessant  calls  to  micturate,  and  the  suffering  induced 
may  produce  serious  constitutional  disturbances.  I  have  elsewhere 
pointed  out,2  that  irritability  of  the  bladder  in  the  latter  months  of 
pregnancy  is  frequently  associated  with  an  abnormal  position  of  the 
foetus,  which  is  placed  transversely  or  obliquely.  The  result  is  either 
that  undue  pressure  is  applied  to  the  bladder,  or  that  it  is  drawn  out 
of  its  proper  position.  [Where  the  foetus  is  anencephalus,  with  the 
defective  head  presenting,  the  calls  to  urinate  are  in  some  cases  a  very 
serious  annoyance,  as  the  foetus  makes  an  unusual  pressure  directly 
on  the  bladder. — -ED.]  The  abnormal  position  of  the  foetus  can 
readily  be  detected  by  palpation,  and  as  readily  altered  by  external 
manipulation.  In  some  of  the  cases  I  have  recorded,  altering  the 
position  of  the  foetus  was  immediately  followed  by  relief;  the  symp- 
toms recurring  after  a  time,  when  the  foetus  had  again  assumed  an 
oblique  position.  Should  the  foetus  frequently  become  displaced,  an 
endeavor  may  be  made  to  retain  it  in  the  longitudinal  axis  of  the 
uterus  by  a  proper  adaptation  of  bandages  or  pads.  In  cases  not 
referable  to  this  cause  we  should  attempt  to  relieve  the  bladder  symp- 
toms by  appropriate  medication,  such  as  small  doses  of  liquor  potassas, 
if  the  urine  be  very  acid ;  tincture  of  belladonna ;  the  decoction  of 
triticum  repens,  an  old  but  very  serviceable  remedy;  and  vaginal 
sedative  pessaries  containing  morphia  or  atropine. 

Incontinence  of  Urine. — Women  who  have  borne  many  children 
are  often  troubled  with  incontinence  of  urine  during  pregnancy,  the 
water  dribbling  away  on  the  slightest  movement.  Through  this 
much  irritation  of  the  skin  surrounding  the  genitals  is  produced,  at- 
tended with  troublesome  excoriations  and  eruptions.  Belief  may  be 
partially  obtained  by  lessening  the  pressure  on  the  bladder  by  an 
abdominal  belt,  while  the  skin  is  protected  by  applications  of  simple 
ointment  or  glycerine. 

Phosphatic  Deposit. — Dr.  Tyler  Smith  has  directed  attention  to  a 
phosphatic  condition  of  the  urine  occurring  in  delicate  women,  whose 
constitutions  are  severely  tried  by  gestation.  This  condition  can 
easily  be  altered  by  rest,  nutritious  diet,  and  a  course  of  restorative 
medicines,  such  as  steel,  mineral  acids,  and  the  like. 

1  Obst.  Trans.,  vol.  xi.  2  Obst.  Trans,  vol.  xiii. 


200  PREGNANCY. 

Leucorrhoea. — A  profuse  whitish  leucorrhoeal  discharge  is  very 
common  during  pregnancy,  especially  in  its  latter  half.  The  discharge 
frequently  alarms  the  patient,  but,  unless  it  is  attended  with  disa- 
greeable symptoms,  it  does  not  call  for  special  treatment.  When  at 
all  excessive,  it  may  lead  to  much  irritation  of  the  vagina  and  ex- 
ternal generative  organs.  The  labia  may  become  excoriated  and 
covered  with  small  aphthous  patches,  and  the  whole  vulva  may  be 
hot,  swollen,  and  tender.  Warty  growths,  similar  in  appearance  to 
syphilitic  condylomata,  are  occasionally  developed  in  pregnant  women, 
unconnected  with  any  specific  taint,  and  associated  with  the  presence 
of  an  irritating  leucorrhoeal  discharge.  According  to  Thibierge,1 
these  resist  local  applications,  such  as  sulphate  of  copper  or  nitrate 
of  silver,  but  spontaneously  disappear  after  delivery.  Inasmuch  as 
the  leucorrhoeal  discharge  is  dependent  on  the  congested  condition  of 
the  generative  organs  accompanying  pregnancy,  we  can  hope  to  do 
little  more  than  alleviate  it.  In  the  severer  forms,  as  has  been  pointed 
out  by  Henry  Bennet,  the  cervix  will  be  found  to  be  abraded  or 
covered  with  granular  erosion,  and  it  may  be,  from  time  to  time, 
cautiously  touched  with  the  nitrate  of  silver,  or  a  solution  of  carbolic 
acid.  Generally  speaking,  we  must  content  ourselves  with  recom- 
mending the  patient  to  wash  the  vagina  out  gently  with  diluted 
Condy's  fluid;  or  with  a  solution  of  the  sulpho-carbolate  of  zinc,  of 
the  strength  of  four  grains  to  the  ounce  of  water ;  or  with  plain  tepid 
water.  For  obvious  reasons  frequent  and  strong  vaginal  douches  are 
to  be  avoided,  but  a  daily  gentle  injection,  for  the  purpose  of  ablution, 
can  do  no  harm. 

Pruritus. — A  very  distressing  pruritus  of  the  vulva  is  frequently 
met  Avith  along  with  leucofrhoea,  especially  when  the  discharge  is  of 
an  acrid  character,  which  in  some  cases  leads  to  intense  and  protracted 
suffering,  forcing  the  patient  to  resort  to  incessant  friction  of  the  parts. 
Pruritus,  however,  may  exist  without  leucorrhoea,  being  apparently 
sometimes  of  a  neuralgic  character,  at  others  associated  with  apthous 
patches  on  the  mucous  membrane,  ascarides  in  the  rectum,  or  pediculi 
in  the  hairs  of  the  mons  veneris  and  labia.  Cases  are  even  recorded 
in  which  the  pruritic  irritation  extended  over  the  whole  body.  The 
treatment  is  difficult  and  unsatisfactory.  Various  sedative  applica- 
tions may  be  tried,  such  as  weak  solutions  of  Goulard's  lotion;  or  a 
lotion  composed  of  an  ounce  of  the  solution  of  the  muriate  of  morphia, 
with  a  drachm  and  a  half  of  hydrocyanic  acid,  in  six  ounces  of  water; 
or  one  formed  by  mixing  one  part  of  chloroform  with  six  of  almond 
oil.  A  very  useful  form  of  medication  consists  in  the  insertion  into 
the  vagina  of  a  pledget  of  cotton-wool,  soaked  in  equal  parts  of  the 
glycerine  of  borax  and  sulphurous  acid.  This  may  be  inserted  at 
bed  time,  and  withdrawn  in  the  morning  by  means  of  a  string  attached 
to  it.  In  the  more  obstinate  cases,  the  solid  nitrate  of  silver  may  be 
lightly  brushed  over  the  vulva;  or,  as  recommended  by  Tarnier,  a 
solution  of  bichloride  of  mercury,  of  about  the  strength  of  two  grs. 
to  the  ounce,  may  be  applied  night  and  morning.  The  state  of  the 

1  Arch.  G6n.  d6  M6d.,  1856. 


DISEASES    OF    PREGNANCY.  201 

digestive  organs  should  always  he  attended  to,  and  aperient  mineral 
water  may  be  usefully  administered.  When  the  pruritus  extends 
beyond  the  vulva,  or  even  in  severe  local  cases,  large  doses  of  bromide 
of  potassium  may  perhaps  be  useful  in  lessening  the  general  hyper- 
aesthetic  state  of  the  nerves. 

Effects  of  Pressure. — Some  of  the  disorders  of  pregnancy  arc  the 
direct  results  of  the  mechanical  pressure  of  the  gravid  uterus.  The 
most  common  of  these  are  oedema  and  a  varicose  state  of  the  veins  of 
the  lower  extremities,  or  even  of  the  vulva.  The  former  is  of  little 
consequence,  provided  we  have  assured  ourselves  that  it  is  really  the 
result  of  pressure,  and  not  of  albuminuria,  and  it  can  generally  be 
relieved  by  rest  in  the  horizontal  position.  A  varicose  state  of  the 
veins  of  the  lower  limbs  is  very  common,  especially  in  multipart,  in 
whom  it  is  apt  to  continue  after  delivery.  Occasionally  the  veins  of 
the  vulva,  and  even  of  the  vagina,  are  also  enlarged  and  varicose, 
producing  considerable  swelling  of  the  external  genitals.  Eest  in 
the  recumbent  position,  and  the  use  of  an  abdominal  belt,  so  as  to 
take  the  pressure  off  the  veins  as  much  as  possible,  are  all  that  can 
be  done  to  relieve  this  troublesome  complication.  If  the  veins  of  the 
legs  are  much  swollen,  some  benefit  may  be  derived  from  an  elastic 
stocking  or  a  carefully  applied  bandage. 

Occasional  serious  results  from  Laceration  of  the  Veins. — Serious  and 
even  fatal  consequences  have  followed  the  accidental  laceration  of 
the  swollen  veins.  When  laceration  occurs  during  or  immediately 
after  delivery — a  not  uncommon  result  of  the  pressure  of  the  head — 
it  gives  rise  to  the  formation  of  a  vaginal  thrombus.  It  has  occa- 
sionally happened  from  an  accidental  injury  during  pregnancy,  as  in 
the  cases  recorded  by  Simpson,  in  which  death  followed  a  kick  on 
the  pudenda,  producing  laceration  of  a  varicose  vein,  or  in  one  men- 
tioned by  Tarnier,  where  the  patient  fell  on  the  edge  of  a  chair. 
Severe  hemorrhage  has  followed  the  accidental  rupture  of  a  vein  in 
the  leg.  The  only  satisfactory  treatment  is  pressure,  applied  directly 
to  the  bleeding  parts  by  means  of  the  finger,  or  by  compresses  satu- 
rated in  a  solution  of  the  perchloride  of  iron.  The  treatment  of 
vaginal  thrombus  following  labor  must  be  considered  elsewhere. 
Occasionally  the  varicose  veins  inflame,  become  very  tender  and 
painful,  and  coagula  form  in  their  canals.  In  such  cases  absolute 
rest  should  be  insisted  on,  while  sedative  lotions,  such  as  the  chloro- 
form and  belladonna  liniments,  should  be  applied  to  relieve  the  pain. 

Displacements  of  the  Gravid  Uterus. — Certain  displacements  of  the 
gravid  uterus  are  met  with,  which  may  give  rise  to  symptoms  of 
great  gravity. 

Prolapse,  which  is  rare,  is  almost  always  the  result  of  pregnancy 
occurring  in  a  uterus  which  had  been  previously  more  or  less  proci- 
dent.  Under  such  circumstances  the  increasing  weight  of  the  uterus 
will  at  first  necessarily  augment  the  previously  existing  tendency  to 
protrusion  of  the  womb,  which  may  come  to  protrude  partially  or 
entirely  beyond  the  vulva.  In  the  great  majority  of  cases,  as  preg- 
nancy advances,  the  prolapsus  cures  itself,  for  at  about  the  fourth  or 
fifth  month  the  uterus  will  rise  above  the  pelvic  brim.  It  has  been 
14 

E   OK   OSTIEOI-ATKU 


202  PREGNANCY. 

said,  that,  in  some  cases  of  complete  procidentia,  pregnancy  has  gone 
on  even  to  term,  with  the  uterus  lying  entirely  outside  the  vulva. 
Most  probably  these  cases  were  imperfectly  observed,  the  greater 
part  of  the  uterus  being  in  reality  above  the  pelvic  brim,  a  portion 
only  of  its  lower  segment  protruding  externally;  or,  as  has  some- 
times been  the  case,  the  protruding  portion  has  been  an  old  standing 
hypertrophic  elongation  of  the  cervix,  the  internal  os  uteri  and  fundus 
being  normally  situated.  Should  a  prolapsed  uterus  not  rise  into 
the  abdominal  cavity  as  pregnancy  advances,  serious  symptoms  will 
be  apt  to  develop  themselves ;  for,  unless  the  pelvis  be  unusually 
capacious,  the  enlarging  uterus  will  get  jammed  within  its  bony 
walls,  the  rectum  and  urethra  will  be  pressed  upon,  defecation  and 
micturition  will  be  consequently  impeded,  and  severe  pain  and  much 
irritation  will  result.  In  all  probability  such  a  state  of  things  would 
lead  to  abortion.  The  possibility  of  these  consequences  should,  there- 
fore, teach  us  to  be  careful  in  the  management  of  every  case  of  prolap- 
sus, however  slight,  in  which  pregnancy  occurs.  Absolute  rest,  in  the 
horizontal  position,  should  be  insisted  on ;  while  the  uterus  should 
be  supported  in  the  pelvis  by  a  full-sized  Hodge's  pessary,  which 
should  be  worn  until  at  least  the  sixth  month,  when  the  uterus  would 
be  fully  within  the  abdominal  cavity.  After  delivery,  prolonged 
rest  should  be  recommended,  in  the  hope  that  the  process  of  involu- 
tion may  be  accompanied  by  a  cure  of  the  prolapse.  There  can  be 
no  doubt  that  pregnancy  carried  to  term  affords  an  opportunity  of 
curing  even  old-standing  displacements,  which  should  not  be  neg- 
lected. 

Anteversion  of  the  gravid  uterus  seldom  produces  symptoms  of 
consequence.  In  all  probability  it  is  common  enough  when  preg- 
nancy occurs  in  a  uterus  which  is  more  than  usually  anteverted,  or 
is  anteflexed.  Under  such  circumstances,  there  is  not  the  same  risk 
of  incarceration  in  the  pelvic  cavity  as  in  cases  in  which  pregnancy 
exists  in  a  retroflexed  uterus,  for,  as  the  uterus  increases  in  size,  it 
rises  without  difficulty  into  the  abdominal  cavity.  In  the  early 
months  the  pressure  of  the  fundus  on  the  bladder  may  account  for 
the  irritability  of  that  viscus  then  so  commonly  observed.  It  will 
be  remembered  that  Graily  Hewitt  attributes  great  importance  to 
this  condition  as  explaining  the  sickness  of  pregnancy — a  theory, 
however,  which  has  not  met  with  general  acceptation. 

Extrem.e  anteversion  of  the  uterus,  at  an  advanced  period  of  preg- 
nancy, is  sometimes  observed  in  multipart  with  very  lax  abdominal 
walls,  occasionally  to  such  an  extent  that  the  uterus  falls  completely 
forwards  and  downwards,  so  that  the  fundus  is  almost  on  a  level 
with  the  patient's  knees.  This  form  of  pendulous  belly  may  be 
associated  with  a  separation  of  the  recti  muscles,  between  which  the 
womb  forms  a  ventral  hernia,  covered  only  by  the  cutaneous  textures. 
When  labor  comes  on  this  variety  of  displacement  may  give  rise  to 
trouble  by  destroying  the  proper  relation  of  the  uterine  and  pelvic 
axes.  The  treatment  is  purely  mechanical,  keeping  the  patient  lying 
on  her  back  as  much  as  possible,  and  supporting  the  pendulous  abdo- 
men by  a  properly  adjusted  bandage.  A  similar  forward  displace- 


DISEASES    OF    PREGNANCY.  203 

ment  is  observed  in  cases  of  pelvic  deformity,  and  in  the  worst  forms, 
in  rachitic  and  d \varfed  women,  it  exists  to  a  very  exaggerated  de- 
gree. [This  uterine  hernia  may  even  be  such  an  obstacle  to  parturi- 
tion as  to  require  the  Ca^sarean  section,  as  in  the  case  reported  by 
Dr.  Harvey,1  of  Eichmond,  Mississippi,  in  1849. — ED.] 

Retroversion. — The  most  important  of  the  displacements,  in  conse- 
quence of  its  occasional  very  serious  results,  is  retroversion  of  the 
gravid  uterus.  It  was  formerly  generally  believed  that  this  was 
most  commonly  produced  by  some  accident,  such  as  a  fall,  which 
dislocated  a  uterus  previously  in  a  normal  position.  Undue  dis- 
tension of  the  bladder  was  also  considered  to  have  an  important 
influence  in  its  production,  by  pressing  the  uterus  backwards  and 
downwards. 

Its  Causes. — It  is  now  almost  universally  admitted  that,  although 
the  above-named  causes  may  possibly  sometimes  produce  it,  in  the 
very  large  proportion  of  cases  it  depends  on  pregnancy  having 
occurred  in  a  uterus  previously  retroverted  or  retroflexed.  The 
merit  of  pointing  out  this  fact  unquestionably  belongs  to  the  late 
Dr.  Tyler  Smith,  and  further  observations  have  fully  corroborated 
the  correctness  of  his  views. 

In  the  large  majority  of  cases  in  which  pregnancy  occurs  in  a 
uterus  so  displaced,  as  the  womb  enlarges,  it  straightens  itself,  and 
rises  into  the  abdominal  cavity,  without  giving  any  particular 
trouble;  or,  as  not  infrequently  happens,  the  abnormal  position  of 
the  organ  interferes  so  much  with  its  enlargement  as  to  produce 
abortion.  Sometimes,  however,  the  uterus  increases  without  leaving 
the  pelvis  until  the  third  or  fourth  month,  when  it  can  no  longer  be 
retained  in  the  pelvic  cavity  without  inconvenience.  It  then  presses 
on  the  urethra  and  rectum,  and  eventually  becomes  completely  in- 
carcerated within  the  rigid  walls  of  the  bony  pelvis,  giving  rise  to- 
characteristic  symptoms. 

Symptoms. — The  first  sign  which  attracts  attention  is  generally 
some  trouble  connected  with  micturition,  in  consequence  of  pressure 
on  the  urethra.  On  examination,  the  bladder  will  often  be  found  to 
be  enormously  distended,  forming  a  large,  fluctuating  abdominal 
tumor,  which  the  patient  has  lost  all  power  of  emptying.  Fre- 
quently small  quantities  of  urine  dribble  away,  leading  the  woman 
to  believe  that  she  has  passed  water,  and  thus  the  distension  is  often 
overlooked.  Sometimes  the  obstruction  to  the  discharge  of  urine  is 
so  great  as  to  lead  to  dropsical  effusion  into  the  cellular  tissue  of  the 
arms  and  legs.  This  was  very  well  marked  in  one  of  my  cases,  and 
disappeared  rapidly  after  the  bladder  had  been  emptied.  Difficulty 
in  defecation,  tenesmus,  obstinate  constipation,  and  inability  to  empty 
the  bowels,  becomes  established  about  the  same  time.  These  symp- 
toms increase,  accompanied  by  some  pelvic  pain  and  a  sense  of  weight 
and  bearing  down,  until  at  last  the  patient  applies  for  advice,  and 
the  true  nature  of  the  case  is  detected.  When  the  retroversion 

['  New  Orleans  Med.  and  Surg.  Journal,  vol.  ix.  p.  7Z2,  1853.] 


204  PREGNANCY. 

occurs  suddenly,  all  these  symptoms  develop  with  great  rapidity, 
and  are  sometimes  very  serious  from  the  first. 

Progress  and  Termination. — The  further  progress  is  various. 
Sometimes,  after  the  uterus  has  been  incarcerated  in  the  pelvis  for 
more  or  less  time,  it  may  spontaneously  rise  into  the  abdominal 
cavity,  when  all  threatening  symptoms  will  disappear.  So  happy  a 
termination  is  quite  exceptional,  and  if  the  practitioner  should  not 
interfere  and  effect  reposition  of  the  organ,  serious  and  even  fatal 
consequences  may  ensue,  unless  abortion  occurs. 

Termination  if  Reduction  is  not  Effected. — The  extreme  distension 
of  the  bladder,  and  the  impossibility  of  relieving  it,  may  lead  to 
lacerations  of  its  coats,  and  fatal  peritonitis ;  or  the  retention  of  urine 
may  produce  cystitis,  with  exfoliation  of  the  coats  of  the  bladder ; 
or,  as  more  commonly  happens,  retention  of  urinary  elements  may 
take  place,  and  death  occur  with  all  the  symptoms  of  uraemic  poison- 
ing. At  other  times  the  impacted  uterus  becomes  congested  and 
inflamed,  and  eventually  sloughs,  its  contents,  if  the  patient  survive, 
being  discharged  by  fistulous  communications  into  the  rectum  and 
vagina.  It  need  hardly  be  said  that  such  terminations  are  only  possi- 
ble in  cases  which  have  been  grossly  mismanaged,  or  the  nature  of 
which  has  not  been  detected  till  a  late  period. 

Diagnosis. — The  diagnosis  is  not  difficult.  On  making  a  vaginal 
examination,  the  finger  impinges  on  a  smooth  rounded  elastic  swell- 
ing, filling  up  the  lower  part  of  the  pelvis,  and  stretching  and  de- 
pressing the  posterior  vaginal  wall,  which  occasionally  protrudes 
beyond  the  vulva.  On  passing  the  finger  forwards  and  upwards  we 
shall  generally  be  able  to  reach  the  cervix,  high  up  behind  the  pubes, 
and  pressing  on  the  urethral  canal.  In  very  complete  retroversion 
it  may  be  difficult  or  impossible  to  reach  the  cervix  at  all.  On  ab- 
dominal examination  the  fundus  uteri  cannot  be  felt  above  the  pelvic 
brim ;  this,  as  the  retroversion  does  not  give  rise  to  serious  symp- 
toms until  between  the  third  and  fourth  months,  should,  under 
natural  circumstances,  always  be  possible.  By  bi-manual  examina- 
tion we  can  make  out,  with  due  care,  the  alternate  relaxation  and 
contraction  of  the  uterine  parietes  characteristic  of  the  gravid  uterus, 
and  so  differentiate  the  swelling  from  any  other  in  the  same  situa- 
tion. The  accompanying  phenomena  of  pregnancy  will  also  prevent 
any  mistake  of  this  kind. 

Retroversion  going  on  to  Term. — In  some  few  cases  retroversion  has 
been  supposed  to  go  on  to  term.  Strictly  speaking,  this  is  impossi- 
ble; but  in  the  supposed  examples,  such  as  in  the  well-known  case 
recorded  by  Oldham,  part  of  a  retroflexed  uterus  remained  in  the 
pelvic  cavity,  while  the  greater  part  developed  in  the  abdominal 
cavity.  The  uterus  is,  therefore,  divided,  as  it  were,  into  two  por- 
tions ;  one,  which  is  the  flexed  fundus,  remaining  in  the  pelvis,  the 
other,  containing  the  greater  part  of  the  foetus,  rising  above  it. 
Under  these  circumstances,  a  tumor  in  the  vagina  would  exist  in 
combination  with  an  abdominal  tumor,  and  pregnancy  might  go  on 
to  term.  Considerable  difficulty  may  even  arise  in  labor,  but  the 


DISEASES    OF    PREGNANCY.  205 

malposition  generally  rectifies  itself  before  it  gives  rise  to  any  serious 
results. 

Treatment. — The  treatment  of  retroversion  of  tlie  gravid  uterus 
should  be  taken  in  hand  as  soon  as  possible,  for  every  day's  delay 
involves  an  increase  in  the  size  of  the  uterus,  and,  therefore,  greater 
difficulty  in  reposition.  Our  object  is  to  restore  the  natural  direc- 
tion of  the  uterus,  by  lifting  the  fundus  above  the  promontory  of  the 
sacrum.  The  first  thing  to  be  done  is  to  relieve  the  patient  by 
emptying  the  bladder,  the  retention  of  urine  having  probably  origi- 
nally called  attention  to  the  case.  For  this  purpose  it  is  essential  to 
use  a  long  elastic  male  catheter  of  small  size,  as  the  urethra  is  too 
elongated  and  compressed  to  admit  of  the  passage  of  the  ordinary 
silver  instrument.  Even  then  it  may  be  extremely  difficult  to  intro- 
duce the  catheter,  and  sometimes  it  has  been  found  to  be  quite  im- 
possible. Under  such  circumstances,  provided  reposition  cannot  be 
effected  without  it,  the  bladder  may  be  punctured  an  inch  or  two 
above  the  pubes  by  means  of  the  fine  needle  of  an  aspirator,  and  the 
urine  drawn  off.  Dieulafoy's  work  on  aspiration  proves  conclusively 
that  this  may  be  done  without  risk,  and  the  operation  has  been  suc- 
cessfully performed  by  Schatz  and  others.  It  very  rarely  happens, 
however,  and  in  long-neglected  cases  only,  that  the  withdrawal  of 
the  urine  is  found  to  be  impossible. 

Mode  of  Effecting  Reduction. — The  bladder  being  emptied,  and  the 
bowels  being  also  opened,  if  possible,  by  copious  enemata,  we  pro- 
ceed to  attempt  reduction.  For  this  purpose  various  procedures  are 
adopted.  If  the  case  is  not  of  very  long  standing,  I  am  inclined  to 
think  that  the  gentlest  and  safest  plan  is  the  continuous  pressure  of 
a  caoutchouc  bag,  filled  with  water,  placed  in  the  vagina.  The  good 
effects  of  steady  and  long-continued  pressure  of  this  kind  were 
proved  by  Tyler  Smith,  who  effected  in  this  way  the  reduction  of  an 
inverted  uterus  of  long  standing,  and  it  is  not  difficult  to  understand 
that  it  may  succeed  when  a  more  sudden  and  violent  effort  fails.  I 
have  tried  this  plan  successfully  in  two  cases,  a  pyriform  India-rub- 
ber bag  being  inserted  into  the  vagina,  and  distended  as  far  as  the 
patient  could  bear  by  means  of  a  syringe.  The  water  must  be  let  out 
occasionally  to  allow  the  patient  to  empty  the  bladder,  and  the  bag 
immediately  refilled.  In  both  my  cases  reposition  occurred  within 
twenty-four  hours.  Barnes  has  failed  with  this  method  ;  but  it  suc- 
ceeded so  well  in  my  cases,  and  is  so  obviously  less  likely  to  prove 
hurtful  than  forcible  reposition  with  the  hand,  that  I  am  inclined  to 
consider  it  the  preferable  procedure,  and  one  that  should  be  tried 
first.  Failing  with  the  fluid  pressure, -we  should  endeavor  to  replace 
the  uterus  in  the  following  way.  The  patient  should  be  placed  at 
the  edge  of  the  bed,  in  the  ordinary  obstetric  position,  and  thoroughly 
anaesthetized.  This  is  of  importance,  as  it  relaxes  all  the  parts,  and 
admits  of  much  freer  manipulation  than  is  otherwise  possible.  One 
or  more  fingers  of  the  left  hand  are  then  inserted  into  the  rectum ; 
if  the  patient  be  deeply  chloroformed,  it  is  quite  possible,  with  due 
care,  even  to  pass  the  whole  hand,  and  an  attempt  is  then  made  to 
lift  or  push  the  fundus  above  the  promonotory  of  the  sacrum.  At 


20G  PREGNANCY. 

the  same  time  reposition  is  aided  by  drawing  down  the  cervix  with 
the  fingers  of  the  right  hand  per  vaginam.  It  has  been  insisted 
that  the  pressure  should  be  made  in  the  direction  of  one  or  other 
sacro-iliac  synchondrosis  rather  than  directly  upwards,  so  that  the 
uterus  may  not  be  jammed  against  the  projection  of  the  promontory 
of  the  sacrum.  Failing  reposition  through  the  rectum,  an  attempt 
may  be  made  per  vaginam,  and  for  this  some  have  advised  the  up- 
ward pressure  of  the  closed  fist  passed  into  the  canal.  Others  recom- 
mend the  hand  and  position  as  facilitating  reposition,  but  this  pre- 
vents the  administration  of  chloroform,  which  is  of  more  assistance 
than  any  change  of  position  can  possibly  be.  Various  complex  in- 
struments have  been  invented  to  facilitate  the  operation,  but  they  are 
all  more  or  less  dangerous,  and  are  unlikely  to  succeed  when  manual 
pressure  has  failed. 

As  soon  as  the  reduction  is  accomplished,  subsequent  descent  of 
the  uterus  should  be  prevented  by  a  large-sized  Hodge's  pessary,  and 
the  patient  should  be  kept  at  rest  for  some  days,  the  state  of  the 
bladder  and  bowels  being  particularly  attended  to.  When  reposition 
has  been  fairly  effected,  a  relapse  is  unlikely  to  occur. 

Treatment  when  Reduction  is  found  Impossible. — In  cases  in  which 
reduction  is  found  to  be  impossible,  our  only  resource  is  the  artificial 
induction  of  abortion.  Under  such  circumstances  this  is  imperatively 
called  for.  It  is  best  effected  by  puncturing  the  membranes,  the  dis- 
charge of  the  liquor  amnii  of  itself  lessening  the  size  of  the  uterus, 
and  thus  diminishing  the  pressure  to  which  the  neighboring  parts 
are  subjected.  After  this  reposition  may  be  possible,  or  we  may 
wait  until  the  foetus  is  spontaneously  expelled.  It  is  not  always  easy 
to  reach  the  os  uteri,  although  we  can  generally  do  so  with  a  curved 
uterine  sound.  If  we  cannot  puncture  the  membranes,  the  liquor 
amnii  may  be  drawn  off  through  the  uterine  walls  by  means  of  the 
aspirator,  inserted  through  either  the  rectum  or  vagina.  The  injury 
to  the  uterine  walls  thus  inflicted  is  not  likely  to  be  hurtful,  and  the 
risk  is  certainly  far  less  than  leaving  the  case  alone.  Naturally  so 
extreme  a  measure  would  not  be  adopted  until  all  the  simpler  means 
indicated  have  been  tried  and  failed. 

Diseases  coexisting  with  Preynancy. — The  pregnant  woman  is,  of 
course,  liable  to  contract  the  same  diseases  as  in  the  non-pregnant 
state,  and  pregnancy  may  occur  in  women  already  the  subject  of 
some  constitutional  disease.  There  is  no  doubt  yet  much  to  be  learned 
as  to  the  influence  of  coexisting  disease  on  pregnancy.  It  is  certain 
that  some  diseases  are  but  little  modified  by  pregnancy,  and  that 
others  are  so  to  a  consi'derable  extent ;  and  that  the  influence  of  the 
disease  on  the  foatus  varies  much.  The  subject  is  too  extensive  to 
be  entered  into  at  any  length,  but  a  few  words  may  be  said  as  to 
some  of  the  more  important  affections  that  are  likely  to  be  met  with. 

Eruptive  Fevers.  Smallpox. — The  eruptive  fevers  have  often  very 
serious  consequences,  proportionate  to  the  intensity  of  the  attack. 
Of  these  variola  has  the  most  disastrous  results,  which  are  related  in 
the  writings  of  the  older  authors,  but  which  are,  fortunately,  rarely 
seen  in  these  days  of  vaccination.  The  severe  and  confluent  forms 


DISEASES    OF    PREGNANCY.  207 

of  the  disease  are  almost  certainly  fatal  to  both  the  mother  and 
child.  In  the  discrete  form,  and  in  modified  smallpox  after  vaccina- 
tion, the  patient  generally  has  the  disease  favorably,  and,  although 
abortion  frequently  results,  it  does  not  necessarily  do  so. 

Scarlet  Fever. — If  scarlet  fever  of  an  intense  character  attacks  a 
pregnant  woman,  abortion  is  likely  to  occur,  and  the  risks  to  the 
mother  arc  very  great.  The  milder  cases  run  their  course  without 
the  production  of  any  untoward  symptoms.  Should  abortion  occur, 
the  well-known  dangerous  effect  of  this  zymotic  disease  after  delivery 
will  gravely  influence  the  prognosis.  Cazeaux  was  of  opinion  that 
pregnant  women  are  not  apt  to  contract  the  disease;  while  Mont- 
gomery thought  that  the  poison  when  absorbed  during  pregnancy 
might  remain  latent  until  deliver}',  when  its  characteristic  effects 
were  produced. 

Measles,  unless  very  severe,  often  runs  its  course  without  seriously 
affecting  the  mother  or  child.  I  have  myself  seen  several  examples 
of  this.  De  Tourcoing,  however,  states  that  out  of  15  cases  the 
mothers  aborted  in  7,  these  being  all  very  severe  attacks.  Some 
cases  are  recorded  in  which  the  child  was  born  with  the  rubeolous 
eruption  upon  it. 

Continued  Fevers. — The  pregnant  woman  may  be  attacked  with 
any  of  the  continued  fevers,  and,  if  they  are  at  all  severe,  they  are 
apt  to  produce  abortion.  Out  of  22  cases  of  typhoid,  16  aborted, 
and  the  remaining  6,  who  had  slight  attacks,  went  on  to  term ;  out 
of  63  cases  of  relapsing  fever,  abortion  or  premature  labor  occurred 
in  23.  According  to  Schweden  the  main  cause  of  danger  to  the 
fetus  in  continued  fevers  is  the  hyperpyrexia,  especially  when  the 
maternal  temperature  reaches  104°  or  upwards.  The  fevers  do  not 
appear  to  be  aggravated  as  regards  the  mother,  and  the  same  ob- 
servation has  been  made  by  Cazeaux  with  regard  to  this  class  of 
disease  occurring  after  delivery. 

Pneum.onia  seems  to  be  specially  dangerous,  for  of  15  cases  collected 
by  Grisolle1  11  died — a  mortality  immensely  greater  than  that  of  the 
disease  in  general.  The  larger  proportion  also  aborted,  the  children 
being  generally  dead,  and  the  fatal  result  is  probably  due,  as  in  the 
severe  continued  fevers,  to  hyperpyrexia.  The  cause  of  the  maternal 
mortality  does  not  seem  quite  apparent,  since  the  same  danger  does 
not  appear  to  exist  in  severe  bronchitis,  or  other  inflammatory 
affections. 

Phthisis. — Contrary  to  the  usually  received  opinion  it  appears 
certain  that  pregnancy  has  no  retarding  influence  on  coexisting 
phthisis,  nor  does  the  disease  necessarily  advance  with  greater 
rapidity  after  delivery.  Out  of  27  cases  of  phthisis,  collected  by 
Grisolle,2  24  showed  the  first  symptoms  of  the  disease  after  pregnancy 
had  commenced.  Phthisical  women  are  not  apt  to  conceive ;  a  fact 
which  may  probably  be  explained  by  the  frequent  coexistence,  in 
such  cases,  of  uterine  disease,  especially  severe  leucorrhoea.  The 
entire  duration  of  the  phthisis  seems  to  be  shortened,  as  it  averaged 

1   Arch.  G6n.  de  M6d.  vol.  xiii.  p.  298.  2  Ibid.  vol.  xxii. 


208  PREGNANCY. 

only  nine  and  a  half  months  in  the  27  cases  collected — a  fact  which 
proves,  at  least,  that  pregnancy  has  no  material  influence  in  arresting 
its  progress.  If  we  consider  the  tax  on  the  vital  powers  which 
pregnancy  naturally  involves,  we  must  admit  that  this  view  is  more 
physiologically  probable  than  the  one  generally  received,  and  appa- 
rently adopted  without  any  due  grounds. 

Heart-disease. — The  evil  effects  of  pregnancy  and  parturition  on 
chronic  heart-disease  have  of  late  received  much  attention  from 
Spiegelberg,  Fritseh,  Peter,  and  other  writers.  The  subject  has  been 
ably  discussed1  in  a  series  of  elaborate  papers  by  Dr.  Angus  Mac- 
Donald,  which  are  well  worthy  of  study.  Out  of  28  cases  collected 
by  him,  17,  or  60  per  cent.,  proved  fatal.  This,  no  doubt,  is  not 
altogether  a  reliable  estimate  of  the  probable  risk  of  the  complica- 
tion ;  but,  at  any  rate,  it  shows  the  serious  anxiety  which  the  occur- 
rence of  pregnancy  in  a  patient  suffering  from  chronic  heart-disease 
must  cause.  Dr.  MacDonald  refers  the  evils  resulting  from  pregnancy 
in  connection  with  cardiac  lesions  to  two  causes:  First,  destruction 
of  that  equilibrium  of  the  circulation,  which  has  been  established 
by  compensatory  arrangements;  secondly,  the  occurrence  of  fresh 
inflammatory  lesions  upon  the  valves  of  the  heart  already  diseased. 

The  dangerous  symptoms  do  not  usually  appear  until  after  the 
first  half  of  the  pregnancy  has  passed,  and  the  pregnancy  seldom 
advances  to  term.  The  pathological  phenomena  generally  met  with 
in  fatal  cases  are  pulmonary  congestion,  especially  of  the  bronchial 
mucous  membrane,  and  pulmonary  oedema,  with  occasional  pneu- 
monia and  pleurisy.  Mitral  stenosis  seems  to  be  the  form  of  cardiac 
lesion  most  likely  to  prove  serious,  and  next  to  this  aortic  incompe- 
tency.  The  obvious  deduction  from  these  facts  is  that  heart-disease, 
especially  when  associated  with  serious  symptoms,  such  as  dyspnoea, 
palpitation,  and  the  like,  should  be  considered  a  strong  contra-indica- 
tion  of  marriage.  When  pregnancy  has  actually  occurred,  all  that 
can  be  done  is  to  enjoin  the  careful  regulation  of  the  life  of  the 
patient,  so  as  to  avoid  exposure  to  cold,  and  all  forms  of  severe 
exertion. 

Syphilis. — The  important  influence  of  syphilis  on  the  ovum  is  fully 
considered  elsewhere.  As  regards  the  mother,  its  effects  are  not 
different  from  those  at  other  times.  It  need  only,  therefore,  be  said 
that,  whenever  indications  of  syphilis  in  a  pregnant  woman  exist,  the 
appropriate  treatment  should  be  at  once  instituted  and  carried  on 
during  her  gestation,  not  only  with  the  view  of  checking  the  pro- 
gress of  the  disease,  but  in  the  hope  of  preventing  or  lessening  the 
risk  of  abortion,  or  of  the  birth  of  an  infected  infant.  So  far  from 
pregnancy  contra-indicating  mercurial  treatment,  there  rather  is  a 
reason  for  insisting  on  it  more  strongly.  As  to  the  precise  medica- 
tion, it  is  advisable  to  choose  a  form  that  can  be  exhibited  continu- 
ously for  a  length  of  time  without  producing  serious  constitutional 
results.  Small  doses  of  the  bichloride  of  mercury,  such  as  one-six- 
teenth of  a  grain,  thrice  daily,  or  of  the  iodide  of  mercury,  answer  this 

1  Obstet.  Journ.  1877. 


DISEASES    OF    PREGNANCY.  209 

purpose  well ;  or,  in  the  early  stages  of  pregnancy,  the  mercurial 
vapor  bath,  or  cutaneous  inunction,  may  be  employed. 

Dr.  Weber,  of  St.  Petersburg,1  has  made  some  observations  shoe- 
ing the  superiority  of  the  latter  methods,  which  lie  found  did  not 
interfere  with  the  course  of  pregnancy  ;  the  contrary  was  the  case 
when  the  mercury  was  administered  by  the  mouth,  probably,  as  he 
supposes,  from  disturbance  of  the  digestive  system.  It  must  be  borne 
in  mind,  that  in  married  women  it  may  sometimes  be  expedient  to 
prescribe  an  anti-syphilitic  course  without  their  knowledge  of  its 
nature,  so  that  inunction  is  not  always  feasible. 

Epilepsy. — The  influence  of  pregnancy  on  epilepsy  does  not  appear 
to  be  as  uniform  as  might  perhaps  be  expected.  In  some  cases  the 
number  and  intensity  of  the  fits  have  been  lessened,  in  others  the 
disease  -becomes  aggravated.  Some  cases  are  even  recorded  in  which 
epilepsy  appeared  for  the  first  time  during  gestation.  On  account 
of  the  resemblance  between  epilepsy  and  eclampsia  there  is  a  natural 
apprehension  that  a  pregnant  epileptic  may  suffer  from  convulsions 
during  delivery.  Fortunately,  this  is  by  no  means  necessarily  the 
case,  and  labor  often  goes  on  satisfactorily  without  any  attack. 

Jaundice,  the  result  of  acute  yellow  atrophy  of  the  liver,  is  occa- 
sionally observed,  and  is  said  to  have  been  sometimes  epidemic. 
Independently  of  the  grave  risks  to  the  mother,  it  is  most  likely  to 
produce  abortion  or  the  death  of  the  foetus.  According  to  Davidson, 
it  originates  in  catarrhal  icterus,  the  excretion  of  the  bile-products 
being  impeded  in  consequence  of  pregnancy,  and  their  retention 
giving  rise  to  the  foetal  blood-poisoning  which  accompanies  the 
severer  forms  of  the  disease.  Slight  and  transient  attacks  of  jaun- 
dice may  occur,  without  being  accompanied  by  any  bad  consequences. 
Their  production  is  probably  favored  by  the  mechanical  pressure  of 
the  gravid  uterus  on  the  intestines  and  the  bile-ducts. 

Carcinoma. — The  occurrence  of  pregnancy  in  a  woman  suffering 
from  malignant  disease  of  the  uterus  is  by  no  means  so  rare  as 
might  be  supposed,  and  must  naturally  give  rise  to  much  anxiety  as 
to  the  result.  The  obstetrical  treatment  of  these  cases  will  be  dis- 
cussed elsewhere.  Should  we  be  aware  of  the  existence  of  the  dis- 
ease during  gestation,  the  question  will  arise  whether  we  should  not 
attempt  to  lessen  the  risks  of  delivery  by  bringing  on  abortion  or 
premature  labor.  The  question  is  one  which  is  by  no  means  easy  to 
settle.  We  have  to  deal  with  a  disease  which  is  certain  to  prove 
fatal  to  the  mother  before  long,  and  the  progress  of  which  is  proba- 
bly accelerated  after  labor,  while  the  manipulations  necessary  to  in- 
duce delivery  may  very  unfavorably  influence  the  diseased  structures. 
Again,  by  such  a  measure  we  necessarily  sacrifice  the  child,  while 
we  are  by  no  means  certain  that  we  materially  lessen  the  danger  to 
the  mother.  The  question  cannot  be  settled  except  on  a  considera- 
tion of  each  particular  case.  If  we  see  the  patient  early  in  pregnancy, 
by  inducing  abortion  we  may  save  her  the  dangers  of  labor  at  term 
—possibly  of  the  Cnesarean  section — if  the  obstruction  be  great. 

1  Alteem.  Med.  Cent.  Zeit.  Feb.  1875. 


210  PREGNANCY. 

Under  such  circumstances,  the  operation  would  be  justifiable.  If  the 
pregnancy  have  advanced  beyond  the  sixth  or  seventh  month,  unless 
the  amount  of  malignant  deposit  be  very  small  indeed,  it  is  probable 
that  the  risks  of  labor  would  be  as  great  to  the  mother  as  a  term, 
and  it  would  then  be  advisable  to  give  her  the  advantage  of  the  few 
months'  delay. 

Ovarian  Tumor. — Cases  are  occasionally  met  with  in  which  preg- 
nancy occurs  in  women  who  are  suffering  from  ovarian  tumor,  and 
their  proper  management  has  given  rise  to  considerable  discussion. 
There  can  be  no  doubt  that  such  cases  are  attended  with  very  danger- 
ous and  often  fatal  consequences,  for  the  abdomen  cannot  well  ac- 
commodate the  gravid  uterus  and  the  ovarian  tumor,  both  increasing 
simultaneously.  The  result  is  that  the  tumor  is  subject  to  much 
contusion  and  pressure,  which  have  sometimes  led  to  the  rupture  of 
the  cyst,  and  the  escape  of  its  contents  into  the  peritoneal  cavity  ;  at 
others  to  a  low  form  of  inflammation,  attended  with  much  exhaustion, 
the  death  of  the  patient  supervening  either  before  or  shortly  after 
delivery.  The  danger  during  delivery  from  the  same  cause,  in  the 
cases  which  go  on  to  term,  is  also  very  great.  Of  13  cases  of  delivery 
by  the  natural  powers,  which  I  collected  in  a  paper  on  "Labor  Com- 
plicated with  Ovarian  Tumor,"1  far  more  than  one-half  proved  fatal. 
[A  lady  of  Philadelphia  gave  birth  to  three  living  children  during  the 
existence  of  an  ovarian  tumor :  all  of  the  children  grew  up  ;  and  the 
mother  fell  a  victim  to  the  disease  at  the  age  of  77,  after  numerous 
tappings,  during  fifty  years. — ED.]  Another  source  of  danger  is 
twisting  of  the  pedicle,  and  consequent  strangulation  of  the  cyst,  of 
which  several  instances  are  recorded.  It  is  obvious,  then,  that  the 
risks  are  so  manifold  that  in  every  case  it  is  advisable  to  consider 
whether  they  can  be  lessened  by  surgical  treatment. 

Methods  of  Treatment. — The  means  at  our  disposal  are  either  to 
induce  labor  prematurely,  to  treat  the  tumor  by  tapping,  or  to  per- 
form ovariotomy.  The  question  has  been  particularly  discussed  by 
Spencer  Wells  in  his  works  on  "  Ovariotomy,"  and  by  Barnes  in  his 
"Obstetric  Operations."  The  former  holds  that  the  proper  course  to 
pursue  is  to  tap  the  tumor  when  there  is  any  chance  of  its  being 
materially  lessened  in  size  by  that  procedure,  but  that  when  it  is 
multilocular,  or  when  its  contents  are  solid,  ovariotomy  should  be 
performed  at  as  early  a  period  of  pregnancy  as  possible.  Barnes,  on 
the  other  hand,  maintains  that  the  safer  course  is  to  imitate  the 
means  by  which  nature  often  meets  this  complication,  and  bring  on 
premature  labor  without  interfering  with  the  tumor.  He  thinks  that 
ovariotomy  is  out  of  the  question,  and  that  tapping  may  be  insuffi- 
cient and  leave  enough  of  the  tumor  to  interfere  seriously  with  labor. 
So  far  as  recorded  cases  go,  they  unquestionably  seem  to  show  that 
tapping  is  not  more  dangerous  than  at  other  times,  and  that  ovario- 
tomy may  be  practised  during  pregnancy  with  a  fair  amount  of  suc- 
cess. Wells  records  10  cases  which  were  surgically  interfered  with. 
In  1  tapping  was  performed,  and  in  9  ovariotomy ;  and  of  these  8 
recovered,  the  pregnancy  going  on  to  term  in  5.  On  the  other  hand, 

1  Obst.  Trans.,  vol.  ix. 


DISEASES    OF    PREGNANCY.  211 

5  cases  were  left  alone,  and  either  went  to  term,  or  spontaneous  pre- 
mature labor  supervened ;  and  of  these  8  died.  The  cases  are  not 
sufficiently  numerous  to  settle  the  question,  but  they  certainly  favor 
the  view  taken  by  Wells  rather  than  that  by  Barnes.  It  is  to  be 
observed  that,  unless  we  give  up  all  hope  of  saving  the  child,  and 
induce  abortion,  the  risk  of  induced  premature  labor,  when  the  preg- 
nancy is  sufficiently  advanced  to  hope  for  a  viable  child,  would  almost 
be  as  great  as  that  of  labor  at  term  ;  for  the  question  of  interference 
will  only  have  to  be  considered  with  regard  to  large  tumors,  which 
would  be  nearly  as  much  affected  by  the  pressure  of  a  gravid  uterus 
at  seven  or  eight  months,  as  by  one  at  term.  Small  tumors  gene- 
rally escape  attention,  and  are  more  apt  to  be  impacted  before  the 
presenting  part  in  delivery.  The  success  of  ovariotomy  during 
pregnancy  has  certainly  been  great,  and  we  'have  to  bear  in  mind 
that  the  woman  must  necessarily  be  subjected  to  the  risk  of  the 
operation  sooner  or  later,  so  that  we  cannot  judge  of  the  case  as  one 
in  which  abortion  terminates  the  risk.  Even  if  the  operation  should 
put  an  end  to  the  pregnancy — and  there  is  at  least  a  fair  chance  that 
it  will  not  do  so — there  is  no  certainty  that  that  would  increase  the 
risk  of  the  operation  to  the  mother,  while  as  regards  the  child  we 
should  only  have  the  same  result  as  if  we  intentionally  produced 
abortion.  On  the  whole,  then,  it  seems  that  the  best  chance  to  the 
mother,  and  certainly  the  best  to  the  child,  is  to  resort  to  the  appa- 
rently heroic  practice  recommended  by  Wells.  The  determination 
must,  however,  be  to  some  extent  influenced  by  the  skill  and  ex- 
perience of  the  operator.  If  the  medical  attendant  has  not  gained 
that  experience  which  is  so  essential  for  a  successful  ovariotomist, 
the  interests  of  the  mother  would  be  best  consulted  by  the  induction 
of  abortion  at  as  early  a  period  as  possible.  One  or  other  procedure, 
is  essential ;  for,  in  spite  of  a  few  cases  in  which  several  successive 
pregnancies  have  occurred  in  women  who  have  had  ovarian  tumors, 
the  risks  are  such  as  not  to  justify  an  expectant  practice.  Should 
rupture  of  the  cyst  occur,  there  can  be  no  doubt  that  ovariotomy 
should  at  once  be  resorted  to,  with  the  view  of  removing  the  lacerated 
cyst  and  its  extravasated  contents. 

Fibroid  Tumors. — Pregnancy  may  occur  in  a  uterus  in  which  there 
are  one  or  more  fibroid  tumors.  If  these  are  situated  low  down  and 
in  a  position  likely  to  obstruct  the  passage  of  the  foetus,  they  may 
very  seriously  complicate  delivery.  When  they  are  situated  in  the 
fundus  or  body  of  the  uterus  they  may  give  rise  to  risk  from  hemor- 
rhage, or  from  inflammation  of  their  own  structure.  Inasmuch  as 
they  are  structurally  similar  to  the  uterine  walls  they  partake  of  the 
growth  of  the  uterus  during  pregnancy,  and  frequently  increase  re- 
markably in  size.  Cazeaux  says — "  I  have  known  them  in  several  in- 
stances to  acquire  a  size  in  three  or  four  months  which  they  would  not 
have  done  in  several  years  in  the  non -pregnant  condition."  Con- 
versely, they  share  in  the  involution  of  the  uterus  after  delivery,  and 
often  lessen  greatly  in  size,  or  even  entirely  disappear.  Of  this  fact  I 
have  elsewhere  recorded  several  curious  examples ; l  and  many  other 

1  Obst.  Trans.,  vols.  v.  xiii.  and  xix. 


212  PREGNANCY. 

instances  of  the  complete  disappearance  of  even  large  tumors  have 
been  described  by  authors  whose  accuracy  of  observation  cannot  be 
questioned. 

Treatment. — The  treatment  will  vary  with  the  position  of  the 
tumor.  If  it  is  such  as  to  be  certain  to  obstruct  the  passage  of  the 
child,  abortion  should  be  induced  as  soon  as  possible.  If  the  tumor 
is  well  out  of  the  way,  this  is  not  so  urgently  called  for.  The  princi- 
pal danger  then  is  that  the  tumor  will  impede  the  post-mortem  con- 
traction of  the  uterus,  and  favor  hemorrhage.  Even  if  this  should 
happen,  the  flooding  could  be  controlled  by  the  usual  means,  espe- 
cially by  the  injection  of  the  perchloride  of  iron.  I  have  seen  several 
cases  in  which  delivery  has  taken  place  under  such  circumstances 
without  any  untoward  accident.  The  danger  from  inflammation  and 
subsequent  extrusion  of  the  fibroid  masses  would  probably  be  as 
great  after  abortion  or  premature  labor,  as  after  delivery  at  term.  It 
seems,  therefore,  to  be  the  proper  rule  to  interfere  when  the  tumors 
are  likely  to  impede  delivery,  and  in  other  cases  to  allow  the  preg- 
nancy to  go  on,  and  be  prepared  to  cope  with  any  complications  as 
they  arise.  The  risks  of  pregnancy  should  be  avoided  in  every  case 
in  which  uterine  fibroids  of  any  size  exist,  the  patients  being  advised 
to  lead  a  celibate  life. 


CHAPTEE  IX. 

PATHOLOGY  OF  THE  DECIDUA  AND  OVUM. 

COMPAKATIVELY  little  is,  unfortunately,  known  of  the  pathological 
changes  which  occur  in  the  mucous  membrane  of  the  uterus  during 
pregnancy.  It  is  probable  that  they  are  of  much  more  consequence 
than  is  generally  believed  to  be  the  case;  and  it  is  certain  that  they 
are  a  frequent  cause  of  abortion. 

Endometritis. — One  of  the  most  generally  observed  probably  de- 
pends on  endometritis  antecedent  to  conception.  When  the  impreg- 
nated ovule  reached  the  uterus,  it  engrafted  itself  on  the  inflamed 
mucous  membrane,  which  was  in  an  unfit  condition  for  its  reception 
and  growth.  A  not  uncommon  result,  under  such  circumstances,  is  the 
laceration  of  some  of  the  decidual  vessels,  extravasation  of  blood  be- 
tween the  decidua  and  the  uterine  walls,  and  consequent  abortion  at 
an  early  stage  of  pregnancy.  AS  this  morbid  state  of  the  uterine 
mucous  membrane  is  likely  to  .continue  after  abortion  is  completed, 
the  same  history  repeats  itself  on  each  impregnation,  and  thus  we 
may  have  constant  early  miscarriages  produced.  It  does  not  neces- 
sarily follow,  however,  that  the  pregnancy  is  immediatedly  terminated 
when  this  state  of  things  is  present.  Sometimes  a  condition  of 


PATHOLOGY    OP    THE    DECIDTJA    AND    OVUM. 


213 


hyperplasia  of  the  decidua  is  produced,  the  membrane  becomes  much 
thickened  and  hypertrophied,  and  the  decidual  cells  are  greatly  in- 
creased in  size  (Fig.  82).  In  other  instances  the  internal  surface  of 
the  decidua  becomes  studded  with  rough  polypoid  growths,1  depend- 


FIG.  82. 


Hypertrophied  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal  * 
Portion.     (After  Duncan.) 

ing  on  proliferation  of  its  interstitial  tissue.  Duncan  has  found  that 
the  hypertrophied  decidua  is  always  in  a  state  of  fatty  degeneration, 
more  advanced  in  some  places  than  in  others.2  The  result  of  these 
alterations  is  frequently  to  produce  dwindling  or  death  of  the  ovum, 
which,  however,  retains  its  connection  with  the  decidua,  until,  after 
a  lapse  of  time,  the  decidua  is  expelled  in  the  form  of  a  thick  tri- 
angular fleshy  substance,  with  the  atrophied  ovum  attached  to  some 
part  of  its  inner  surface.  In  other  cases,  in  which  the  hyperplasia 
has  advanced  to  a  less  extent,  the  nutrition  of  the  foetus  is  not  inter- 
fered with,  and  pregnancy  may  continue  to  term,  the  changes  in  the 
decidua  being  recognizable  after  delivery.  Other  diseases  besides 
endometritis  may  give  rise  to  similar  alterations  in  the  decidua,  one 
of  these  being,  as  Virchow  maintains,  syphilis.  The  converse  con- 


1  Virchow's  Archiv  fUr  Path.  1868. 


2  Researches  in  Obstetrics,  p.  293. 


214 


PREGNANCY. 


Imperfectly  developed  Decidua  Vera,  with  the 
Ovum.     (After  Duncan.) 


Fin.  8.°>.  dition,  and    imperfect   develop- 

ment of  the  deeidua,  especially 
of  the  deeidua  reflexa,  has  also 
been  noted  as  a  cause  of  abor- 
tion. The  ovum  will  then  hang 
loosely  in  the  uterine  cavity, 
without  the  support  which  the 
growth  of  the  deeidua  reflexa 
around  it  ought  to  afford,  and 

. 

its  premature  expulsion  readily 
follows  (Fig.  83). 

Hydrorrhoea  Gravidarum. — 
The  peculiar  condition  known 
as  hydrorrhoea  gravidarum  most 
probably  depends  on  some  ob- 
scure morbid  state  of  the  uterine 
mucous  membrane.  By  this  is 
meant  a  discharge  of  clear  water  v 
fluid  at  intervals  during  preg- 
nancy. It  may  happen  at  any 
period  of  gestation,  but  it  is  most  commonly  met  with  in  the  latter 
months.  It  may  commence  with  a  mere  dribbling,  or  there  may  be 
a  sudden  and  copious  discharge  of  fluid.  Afterwards  the  watery 
fluid,  which  is  generally  of  a  pale  yellowish  color,  and  transparent, 
like  the  liquor  amnii,  may  continue  to  escape  at  intervals  for  many 
weeks,  and  sometimes  in  very  great  abundance,  so  as  to  saturate  the 
patient's  clothes.  Very  frequently  it  is  expelled  in  gushes,  and  at 
night,  when  the  patient  is  lying  quietly  in  bed ;  its  escape  is  then 
probably  due  to 'uterine  contraction. 

Many  theories  have  been  held  as  to  its  cause.  By  some  it  is 
attributed  to  the  rupture  of  a  cyst  placed  between  the  ovum  and  the 
uterine  walls ;  Baudelocque  referred  it  to  a  transudation  of  the  liquor 
amnii  through  thf  membranes ;  while  Burgess  and  Dubois  believed 
it  to  depend  on  a  laceration  of  the  membranes  at  a  distance  from  the 
os  uteri.  Mattel  more  recently  has  attributed  it  to  the  existence  of 
a  sac  between  the  chorion  and  the  amnion.  It  may  be  that  in  some 
instances  a  single  discharge  of  fluid  may  come  from  one  of  the  two 
last-mentioned  causes.  But  if  it  be  continuous  or  repeated,  another 
source  must  be  sought  for.  Hegar1  maintains  that  it  is  the  result  of 
abundant  secretion  from  the  glands  of  the  mucous  membrane,  which 
accumulates  between  the  deeidua  and  chorion,  and  escapes  through 
the  os  uteri.  If  this  occur  the  deeidua  is  probably  in  an-hypertro- 
phied  and  otherwise  morbid  state.  Hydrorrhoea  is  chiefly  of  interest 
from  the  error  of  diagnosis  it  is  likely  to  give  rise  to ;  for.  on  being 
summoned  to  a  case  in  which  watery  discharge  has  occurred  for  the 
first  time,  we  are  naturally  apt  to  suppose  that  the  membranes  have 
ruptured,  and  that  labor  is  imminent.  Nor  is  there  any  very  certain 
means  of  deciding  if  this  be  so.  In  hydrorrhoea,  we  find  that  pains 


1  Monat.  f.  Geburt.,  1863. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


215 


FIG.  84. 


are  absent,  the  os  uteri  unopened,  and  ballotternent  may  be  made 
out.  Even  if  the  membranes  be  ruptured,  there  will  be  no  indica- 
tion for  interference  unless  labor  has  actually  commenced ;  and  the 
repetition  of  the  discharge,  and  the  continuance  of  the  pregnancy, 
will  soon  clear  up  the  diagnosis.  Ilydrorrhoea,  although  apt  to 
alarm  the  patient,  need  not  give  rise  to  any  anxiety.  The  pregnancy 
generally  progresses  favorably  to  the  full  period  ;  although,  in  excep- 
tional cases,  premature  labor  may  supervene  No  treatment  is  neces- 
sary, nor  is  there  any  that  could  have  the  least  effect  in  controlling 
the  discharge. 

Pathology  of  the  Chorion. —  The  only  important  disease  of  the 
chorion,  with  which  we  are  acquainted,  is  the  well-known  condition 
which  is  variously  described  as  uterine  hydatids,  cystic  disease  of  the 
ovum,  hydatiform  degeneration  of  the  chorion,  or  vesicular  mole.  The 
name  of  uterine  hydatids  was  long  given  to  it  on  the  supposition  that 
the  grapelike  vesicles,  which  characterize  the  disease,  were  true  hyda- 
tids, similar  to  those  which  develop  in  the  liver  and  other  structures. 
This  idea  has  long  been  exploded,  and  it  is  now  known  as  a  certainty 
that  the  disease  originates  in  the  villi  of  the  chorion.  The  precise 
mode  and  the  causes  of  its  production,  are,  however,  not  yet  satisfac- 
torily settled.  The  disease  is  character- 
ized by  the  existence  in  the  cavity  of  the 
uterus  of  a  large  number  of  translucent 
vesicles,  containing  a  clear  limpid  fluid, 
which  has  been  found  on  analysis  to  bear 
close  resemblance  to  the  liquor  amnii. 
These  small  bladder-like  bodies,  which 
vary  in  size  from  that  of  a  millet-seed  to 
an  acorn,  are  often  described  as  resem- 
bling a  bunch  of  grapes  or  currants.  On 
more  minute  examination,  they  are  found 
not  to  be  each  attached  to  independent 
pedicles,  as  is  the  case  in  a  bunch  of 
grapes,  but  some  of  them  grow  from 
other  vesicles,  while  others  have  distinct 
pedicles  attached  to  the  chorion,  the  pedi- 
cles themselves  sometimes  being  dis- 
tended by  fluid  (Fig.  84).  This  peculiar 
arrangement  of  the  vesicles  is  explained 
by  their  mode  of  growth. 

Causes  of  Cystic  Degeneration. — There 
has  been  considerable  discussion  as  to 
the  etiology  of  this  disease.  By  some  it 
is  supposed  always  to  follow  death  of 
the  foetus ;  and  the  whole  developmental 
energy  being  expended  on  the  chorion,  which  retains  its  attachment 
to  the  decidua,  the  result  is  its  abnormal  growth  and  cystic  degenera- 
tion. This  is  the  view  maintained  by  Gierse  and  Graily  Hewitt,  and 
it  is  favored  by  the  undoubted  fact  that  in  almost  all  cases  the  foetus 
has  entirely  disappeared  ;  and  by  the  occasional  occurrence  of  cases 


Hydatiform  Degeneration  of  the 
Chorion. 


216  PREGNANCY. 

of  twin  conceptions  in  which  one  chorion  has  degenerated,  the  other 
remaining  healthy  until  term.  On  the  other  hand,  it  is  maintained 
that  the  starting-point  is  connected  with  the  maternal  organism. 
Virchow  thinks  it  originates  in  a  morbid  state  of  the  decidua  ;  while 
others  have  attributed  it  to  some  blood  dyscrasia  on  the  part  of  the 
mother,  such  as  syphilis.  There  are  many  reasons  for  believing  that 
causes  of  this  nature  may  originate  the  affection.  Tims  it  is  often  found 
to  occur  more  than  once  in  the  same  person ;  and  alterations  of  a  simi- 
lar kind,  although  limited  in  extent,  are  not  unfrequentiy  found  in 
connection  with  the  placenta  and  membranes  of  living  children.  On 
this  theory  the  death  of  the  foetus  is  secondary,  the  consequence  of 
impaired  nutrition  from  the  morbid  state  of  the  chorion.  The  prob- 
ability is  that  both  views  may  be  right,  the  disease  sometimes  fol- 
lowing the  death  of  the  embryo,  and  at  others  being  the  result  of 
obscure  maternal  causes. 

Pathology. — The  degeneration  of  the  chorion  villi  generally  com- 
mences at  an  early  period  of  pregnancy,  before  the  placenta  has  com- 
menced to  form.  In  that  case  the  entire  superficies  of  the  chorion 
becomes  affected.  The  disease,  however,  may  not  begin  until  after 
the  greater  part  of  the  chorion  villi  has  atrophied,  and  then  it  is  lim- 
ited to  the  placenta.  The  epithelium  of  the  villi  appears  to  be  the 
part  first  affected,  and  the  whole  interior  of  the  diseased  villus 
becomes  filled  with  cells.  The  connective  tissue  of  the  villus  under- 
goes a  remarkable  proliferation,  and  collects  in  masses  at  individual 
spots,  the  remainder  of  the  villus  being  unaffected.  By  the  growth 
of  these  elements  the  villus  becomes  distended,  and  many  of  the  cells 
liquefy,  the  intercellular  fluid,  thus  produced,  widely  separating  the 
connective  tissue,  so  as  to  form  a  network  in  the  interior  of  the  vil- 
lus.1 Thus  are  formed  the  peculiar  grapelike  bodies  which  charac- 
terize the  disease.  When  once  the  degeneration  has  commenced,  the 
diseased  tissue  has  a  remarkable  power  of  increase,  so  that  it  some- 
times forms  a  mass  as  large  as  a  child's  head,  and  several  pounds  in 
weight. 

The  nutrition  of  the  altered  chorion  is  maintained  by  its  connec- 
tion with  the  decidua,  which  is  also  generally  diseased  and  hypertro- 
phied.  Sometimes  the  adhesion  of  the  mass  to  the  uterine  walls  is 
very  firm,  and  may  interfere  with  its  expulsion  ;  while,  in  a  few  rare 
cases,  it  has  been  found  that  the  villi  have  forced  their  way  into  the 
substance  of  the  uterus,  chiefly  through  the  uterine  sinuses,  and  thus 
caused  atrophy  and  thinning  of  its  muscular  structure.  Cases  of 
this  kind  are  related  by  Volkmann,  Waldeyer.2  and  Barnes,  and  it  is 
obvious  that  the  intimate  adhesion  thus  effected  must  seriously  add 
to  the  gravity  of  the  prognosis. 

Medico-legal  Questions. — Taking  this  view  of  the  etiology  of  this 
disease,  it  is  obvious  that  it  is  essentially  connected  with  pregnancy, 
and  that  there  is  no  valid  ground  for  maintaining,  as  has  sometimes 
been  done,  that  it  may  occur  independently  of  conception.  It  is  just 

1  Braxton  Hicks,  Guy's  Hospital  Reports,  vol.  ii.     Third  Series,  p.  183. 

2  Virchow's  Archiv,  vol.  xliv.  p.  88. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  217 

possible,  however,  that  true  entozoa  may  form  in  the  substance  of 
the  uterus,  which  being  expelled  per  vaginam,  might  be  taken  for 
the  results  of  cystic  disease,  and  thus  give  rise  to  groundless  suspi- 
•cions  as  to  the  patient's  chastity.  Hewitt  has  related  one  case  in 
which  true  hydatids,  originally  formed  in  the  liver,  had  extended  to 
the  peritoneum,  and  were  about  to  burst  through  the  vagina  at  the 
time  of  death.  This  occurred  in  an  unmarried  woman.  One  or  two 
other  examples  of  true  hydatids  forming  in  the  substance  of  the  ute- 
rus are  also  recorded.  A  very  interesting  case  is  also  related  by 
Hewitt,1  in  which  undoubted  acephalocysts  were  expelled  from  the 
uterus  of  a  patient  who  ultimately  recovered.  A  careful  examina- 
tion of  the  cyst  and  its  contents  would  show  their  true  nature,  as  the 
echinococci  heads,  with  their  characteristic  booklets,  would  be  dis- 
coverable by  the  microscope. 

It  is  also  possible  that  unfounded  suspicions  might  arise  from  the 
fact  of  a  patient  expelling  a  mass  of  hydatids  long  after  impregnation. 
In  the  case  of  a  widow,  or  woman  living  apart  from  her  husband, 
serious  mistakes  might  thus  be  made.  This  has  been  specially 
pointed  out  by  McClintock,2  who  says,  "Hydatids  maybe  retained  in 
utero  for  many  months  or  years,  or  a  portion  only  may  be  expelled, 
and  the  residue  may  throw  out  a  fresh  crop  of  vesicles,  to  be  dis- 
charged on  a  future  occasion." 

Symptoms  and  Progress  of  the  Disease. — The  symptoms  of  cystic 
disease  of  the  ovum  are  by  no  means  well  marked.  At  first  there  is 
nothing  to  point  to  the  existence  of  any  morbid  condition,  but  as 
pregnancy  advances  its  ordinary  course  is  interfered  with.  There  is 
more  general  disturbance  of  the  health  than  there  ought  to  be,  and 
the  reflex  irritations,  such  as  vomiting,  may  be  unusually  developed. 
The  first  physical  sign  remarked  is  rapid  increase  of  the  uterine 
tumor,  which  soon  does  not  correspond  in  size  to  the  supposed  period 
of  pregnancy.  Thus,  at  the  third  month,  the  uterus  may  be  found 
to  reach  up  to,  or  beyond,  the  umbilicus.  About  this  time  there 
generally  are  more  or  less  profuse  watery  and  sanguineous  dis- 
charges, which  have  been  described  as  resembling  currant  juice. 
They  no  doubt  depend  on  the  breaking  down  and  expulsion  of  the 
cysts,  caused  by  painless  uterine  contractions.  They  are  sometimes 
excessive  in  amount,  recur  with  great  frequency,  and  often  reduce 
the  patient  extremely.  Portions  of  cysts  may  now  generally  be  found 
mingled  with  the  discharge,  and  sometimes  large  masses  of  them  are 
expelled  from  time  to  time.  Indeed,  the  discovery  of  portions  of 
cysts  is  the  only  certain  diagnostic  sign.  Vaginal  examination, 
before  the  os  has  dilated,  will  give  no  information,  except  the  absence 
of  ballottement.  An  unusual  hardness  or  density  of  the  uterus — 
described  by  Leishman,  who  attributes  much  importance  to  it,  as  "a 
peculiar  doughy,  boggy  feeling" — has  been  pointed  out  by  several 
writers.  The  contour  of  the  uterine  tumor,  moreover,  is  often  irregu- 
lar. In  addition,  we,  of  course,  fail  to  discover  the  usual  ausculta- 
tory  signs  of  pregnancy.  All  this  may  aid  in  diagnosis,  but  nothing, 

1  Obstet.  Trans.,  vol.  xii.  2  McClintock's  Diseases  of  Women,  p.  398. 

15 


218  PREGNANCY. 

except  the  presence  of  cysts  in  the  watery  bloody  discharge,  will 
enable  us  to  pronounce  with  certainty  as  to  the  nature  of  the  disease. 

Treatment. — As  soon  as' the  diagnosis  is  established,  the  indications 
for  treatment  are  obvious.  The  sooner  the  uterus  is  cleared  of  its 
contents  the  better.  Ergot  may  be  given  with  advantage  to  favor 
uterine  contraction,  and  the  expulsion  of  the  diseased  ovum.  Should 
this  fail,  more  especially  if  the  hemorrhage  be  great,  the  fingers,  or 
the  whole  hand,  must  be  introduced  into  the  uterus,  and  as  much  as 
possible  of  the  mass  removed.  As  the  os  is  likely  to  be  closed,  its 
preliminary  dilatation  by  sponge  or  laminaria  tents,  or  by  a  Barnes's 
bag,  if  it  be  already  opened  to  some  extent,  will  in  most  cases  be 
required.  If  chloroform  be  then  administered,  the  remaining  steps 
of  the  operation  will  be  easy.  On  account  of  the  occasional  firm 
adhesion  of  the  cystic  mass  to  the  uterus,  too  energetic  attempts  at 
complete  separation  should  be  avoided.  Any  severe  hemorrhage 
after  the  operation  can  be  controlled  by  swabbing  out  the  uterine 
cavity  with  the  perchloride  of  iron  solution. 

Under  the  name  of  Myxoma  jibrosum,  a  more  rare  degeneration  of 
the  chorion  has  been  described  by  Virchow  and  Hildebrandt,1  char- 
acterized, not  by  vesicular,  but  fibroid  degeneration  of  the  connective 
tissue  of  the  chorion.  This  is,  however,  too  little  understood  to 
require  further  observation. 

Pathology  of  the  Placenta. — The  pathology  of  the  placenta  has  of 
late  years  attracted  much  attention,  and  it  has  an  important  practical 
bearing  in  consequence  of  its  effects  on  the  child. 

Placentae  vary  considerably  in  shape.  They  may  be  crescentic,  or 
spread  over  a  considerable  surface,  in  consequence  of  the  chorion 
villi  entering  into  communication  with  a  larger  portion  of  the  de- 
cidua  than  usual  (Placenta  membranacea).  Such  forms,  however, 
are  merely  of  scientific  interest.  The  only  anomaly  of  shape  of  any 
practical  importance  is  the  formation  of  what  have  been  called  pla- 
centae succenturise.  These  consist  of  one  or  more  separate  masses  of 
placental  tissue,  produced  by  the  development  of  isolated  patches  of 
chorion  villi.  Hohl  believes  that  they  always  form  exactly  at  the 
junction  of  the  anterior  and  posterior  walls  of  the  uterus,  which  in 
early  pregnancy  is  a  mere  line.  As  the  uterus  expands,  the  portions 
of  placenta,  on  each  side  of  this,  become  separated  from  each  other. 
They  are  only  of  consequence  from  the  possibility  of  their  remain- 
ing unnoticed  in  the  uterus  after  delivery,  and  giving  rise  to  second- 
ary post-partum  hemorrhage.  The  rare  form  of  double  placenta 
with  a  single  cord,  figured  in  the  accompanying  woodcut  (Fig.  85), 
was  probably  formed  in  this  way,  and  the  supplementary  portion,  in 
such  a  case,  might  readily  escape  notice. 

The  placenta  may  also  vary  in  dimensions.  Sometimes  it  is  of 
excessive  size,  generally  when  the  child  is  unusually  big ;  but  not 
infrequently  in  connection  with  hydramnios,  the  child  being  dead 
and  shrivelled.  In  other  cases  it  is  remarkably  small,  or  at  least 
appears  to  be  so.  If  the  child  be  healthy,  this  is  probably  of  no 

1  Monat.  f.  Geburt,  May,  1865. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 

pathological  importance,  as  its  smallness  may  be  more  apparent  tlian 
real,  depending  on  its  vessels  not  being  distended  with  blood.  "When 
true  atrophy  of  the  placenta  exists,  the  vitality  of  the  foetus  may  be 
seriously  interfered  with.  This  condition  may  depend  either  on  a 
diseased  state  of  the  cborion  villi,  or  of  the  decidua  in  which  they 
are  implanted.1  The  latter  is  the  more  common  of  the  two ;  and  it 
generally  consists  in  hyperplasia  of  the  connective  tissue  of  the  de- 
cidua, which  presses  on  the  villi  and  vessels,  and  gives  rise  to  gen- 
eral or  local  atrophy.  This  change  is  similar  in  its  nature  to  that 
observed  in  cirrhosis  of  the  liver,  and  certain  forms  of  Bright's  dis- 
ease. It  has  generally  been  ascribed  to  inflammatory  changes,  and, 
under  the  name  of  placentitis,  has  been  described  by  many  authors, 


Double  Placenta,  with  single  cord. 

and  has  been  considered  to  be  a  common  disease.  To  it  are  attributed 
many  of  the  morbid  alterations  which  are  commonly  observed  in 
placentae,  such  as  hepatization,  circumscribed  purulent  deposits,  and 
adhesions  to  the  uterine  walls.  Many  modern  pathologists  have 
doubted  whether  these  changes  are  in  any  proper  sense  inflammatory. 
Whittaker  observes  on  this  point :  "  The  disposition  to  reject  pla- 
centitis  altogether  increases  in  modern  times.  Indeed,  it  is  impos- 
sible to  conceive  of  inflammation  on  the  modern  theory  (Cohnheim) 
of  that  process,  since  there  are  no  capillaries,  in  the  maternal  portion 

1  Whittaker,  Amer.  Journ.  of  Obst.,  vol.  iii.,  p.  229. 


220 


PREGNANCY. 


at  least,  through  whose  walls  a  'migration'  might  occur,  and  there 
are  no  nerves  to  regulate  the  contractility  of  the  vessel -walls  in  the 
entire  structure."  Robin  thus  explains  the  various  pathological 
changes  above  alluded  to:  "What  has  been  taken  for  inflammation 
of  the  placenta  is  nothing  else  than  a  condition  of  transformation  of 
blood  clots  at  various  periods.  What  has  been  regarded  as  pus  is 
only  fibrine  in  the  course  of  disorganization,  and  in  those  cases 
where  true  pus  has  been  found  the  pus  did  not  corne  from  the  pla- 

FIG.  86. 


Fatty  Degeneration  of  the  Placenta. 

centa,  but  from  an  inflammation  of  the  tissue  of  the  uterine  vessels 
and  an  accidental  deposition  in  the  tissue  of  the  placenta."  The 
extravasations  of  blood  here  alluded  to  are  of  very  common  occur- 
rence, and  they  are  found  in  all  parts  of  the  organ ;  in  its  substance, 
on  its  decidual  surface,  or  immediately  below  the  amnion,  where 
they  serve  as  points  of  origin  for  the  cysts  that  are  there  often 
observed.  The  fibrine  thus  deposited  undergoes  retrograde  meta- 
morphosis as  in  other  parts  of  the  body :  it  becomes  decolorized,  it 
undergoes  fatty  degeneration  or  becomes  changed  into  calcareous 
masses ;  and  in  this  way,  it  is  supposed,  may  be  explained  the  vari- 
ous pathological  changes  which  are  so  commonly  observed.  The 
amount  of  retrograde  metamorphosis,  and  the  precise  appearance 
presented  will,  of  course,  depend  on  the  time  that  has  elapsed  since 
the  blood  extravasations  took  place. 

Fatty  degeneration  of  the  placenta,  and  its  influence  on  the  nutri- 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM. 


221 


tion  of  the  foetus,  have  been  specially  studied  in  this  country  by 
Barnes  and  Druitt.  Yellowish  masses  of  varying  size  arc  very 
commonly  met  with  in  placenta',  and  these  are  found  to  consist,  in 
great  part,  of  molecular  fat,  mixed  with  a  fine  network  of  fibrous 
tissue.  The  true  fatty  degeneration,  however,  specially  affects  the 
chorion  villi  (Fig.  86).  On  microscopic  examination  they  are  found 
to  be  altered  and  misshaped  in  their  contour,  and  to  be  loaded  with 
fine  granular  fat-globules.  Similar  changes  are  observed  in  the  cells 
of  the  decidua.  The  influence  on  the  foetus  will,  of  course,  depend 
on  the  extent  to  which  the  functions  of  the  villi  are  interfered  with. 
The  probable  cause  of  this  degeneration  is,  no  doubt,  some  obscure 
alteration  in  the  nutrition  of  the  tissue,  depending  on  the  state  of  the 
mother's  health.  Barnes  believes  that  syphilis  has  much  influence 
in  its  production.  Druitt  has  pointed  out  that  some  amount  of  fatty 
degeneration  is  always  present  in  a  mature  placenta,  and  is  probably 
connected  with  the  physiological  separation  of  the  organ ;  and  Goodell 
has  more  recently  suggested  that  an  unusual  amount  of  this  change 
may  be  merely  an  anticipation  of  the  natural  termination  of  the  life 
of  the  placenta.1 

Other  morbid  states  of  the  placenta,  of  greater  rarity,  are  occasionally 
met  with,  as  an  cedematous  infiltration  of  its  tissue,  always  occurring, 
according  to  Lange,  in  cases  of  hydramnios ;  pigmentary  and  calca- 
reous deposits;  and  tumors  of  various  kinds:  but  these  require  only 
a  passing  mention. 

Pathology  of  the  Umbilical  Cord. — The  umbilical  cord  may  be  of 
excessive  length,  varying  from  18  to  20  inches,  which  is  its  average 
measurement,  up  to  50  or  60  inches,  and 
a  case  is  recorded  in  which  it  even  reached 
the  extraordinary  length  of  9  feet.  If 
unusually  long  it  may  be  twisted  round 
the  limbs  or  neck  of  the  child,  and  the 
latter  position  may,  in  exceptional  in- 
stances, prove  injurious  during  labor. 

Some  authors  refer  cases  of  spontane- 
ous amputation  of  foetal  limbs  in  utero 
to  constrictions  by  the  umbilical  cord, 
but  this  accident  is  more  probably  pro- 
duced by  filamentous  adnexa  of  the 
amnion.  Knots  in  the  cord  are  not  un- 
common, and  they  result  from  the  foetus, 
in  its  movements,  passing  through  a  loop 
of  the  cord  (Fig.  87).  If  there  is  an 
average  amount  of  Wharton's  jelly  in 
the  cord  the  vessels  are  protected  from 
pressure,  and  no  bad  effects  follow.  Grdry, 
in  a  recent  paper  on  this  subject,2  at- 
tempts to  show  that  such  knots  are  more 


FIG.  87. 


Knots  of  the  Umbilical  Cord. 


1  American  Journal  of  Obstetrics,  vol.  ii.  p.  535. 

2  L' Union  MSdicale,  Oct.,  1876. 


222  PREGNANCY. 

important  than  is  generally  believed,  and  relates  two  cases  in  which 
he  believes  them  to  have  caused  the  death  of  the  foetus. 

Extreme  torsion  of  the  cord,  an  exaggeration  of  the  spiral  twists 
generally  observed,  may  prove  injurious,  and  even  fatal,  to  the  child 
by  obstructing  the  circulation  in  the  vessels.  Spaeth  mentions  three 
cases  in  which  this  caused  the  death  of  the  foetus,  the  cord  being 
twisted  until  it  was  reduced  to  the  thickness  of  a  thread. 

Anomalies  in  the  distribution  of  the  vessels  of  the  cord  are  of 
common  occurrence.  The  cord  may  be  attached  to  the  edge,  instead 
of  to  the  centre,  of  the  placenta  (battledore  placenta).  It  may  break 
up  into  its  component  parts  before  reaching  the  placenta,  the  vessels 
running  through  the  membranes ;  and  if,  in  such  a  case,  traction  on 
the  cord  be  made,  the  separate  vessels  may  lacerate,  and  the  cord 
become  detached.  There  may  be  two  veins  and  one  artery,  or  only 
one  vein  and  one  artery,  or  there  may  be  two  separate  cords  to  one 
placenta.  These,  and  other  anomalies  that  might  be  mentioned,  are 
of  little  practical  importance. 

The  principal  pathological  condition  of  the  amnion  with  which  we 
are  acquainted  is  that  which  is  associated  with  excessive  secretion  of 
liquor  arnnii,  and  is  generally  known  under  the  name  of  hydramnios. 
Its  precise  cause  is  still  a  matter  of  doubt.  By  some  it  is  referred  to 
inflammation  of  the  amnion  itself;  at  other  times  it  is  apparently 
connected  with  some  morbid  state  of  the  decidua,  which  may  be 
found  diseased  and  hypertrophied.  The  fcstus  is  very  often  dead 
and  shrivelled,  and  the  placenta  enlarged  and  cedematous.  It  does 
not  necessarily  follow,  however,  that  hydramnios  causes  the  death  of 
the  child.  Out  of  33  cases  McClintock  found  that  9  children  were 
born  dead  j1  and  of  the  19  born  alive,  10  died  within  a  few  hours,  the 
remainder  survived.  There  does  not  appear  to  be  any  marked  rela- 
tion between  the  state  of  the  mother's  health  and  the  occurrence  of 
this  disease ;  and  it  is  certainly  not  necessarily  present  when  the 
mother  is  suffering  from  dropsical  effusions  in  other  parts  of  the 
body.  The  theory  that  the  disease  is  of  purely  local  origin  is  favored 
by  the  fact,  that  when  hydramnios  occurs  in  twin  pregnancy,  one 
ovum  only  is  generally  affected.  Its  effects,  as  regards  the  mother, 
are  chiefly  mechanical.  It  rarely  begins  to  show  itself  before  the 
fifth  or  sixth  month  of  pregnancy,  but,  when  once  it  has  commenced, 
it  rapidly  produces  a  feeling  of  discomfort  and  enlargement,  alto- 
gether beyond  that  which  should  exist  at  the  period  of  pregnancy 
which  has  been  reached.  In  advanced  stages  the  distress  produced 
is  often  very  great,  the  enlarged  uterus  pressing  upon  the  diaphragm, 
and  producing  much  embarrassment  of  respiration.  Premature 
expulsion  of  the  foetus  very  often  supervenes.  Four  out  of  McClin- 
tock's  patients  died  after  labor,  showing  that  the  maternal  mortality 
is  high,  a  result  which  he  refers  to  the  debilitated  state  of  the  women 
who  were  the  subjects  of  the  disease. 

Diagnosis. — The  diagnosis  is  not,  as  a  rule,  difficult.  It  has  to  be 
distinguished  from  ascitic  distension  of  the  abdomen,  and  from  en- 

1  Diseases  of  Women,  p.  383. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  223 

largement  of  the  uterus  from  twin  pregnancy.  The  former  will  be 
recognized  by  the  superficial  position  of  the  fluid;  the  difficulty  of 
feeling  the  contour  of  the  uterus,  which  is  obscured  by  the  surround- 
ing fluid ;  and  by  the  coexistence  of  dropsical  effusions  in  other 
parts  of  the  body.  The  latter  may  be  difficult,  and  even  impossible, 
to  diagnose  from  it :  generally,  however,  in  hydramnois  the  uterine 
tumor  is  more  distinctly  tense  or  fluctuating;  the  foetal  limbs  cannot 
be  felt  on  palpation  ;  and  the  lower  segment  of  the  uterus,  as  felt  per 
vaginam,  is  unusually  distended,  the  presenting  part  not  being  ap- 
preciable. 

Its  effect  on  Labor. — During  labor  an  excessive  amount  of  liquor 
amnii  is  often  a  cause  of  deficient  uterine  action  and  delay,  the  pains 
being  feeble  and  ineffective.  This,  of  course,  tells  chiefly  in  the  first 
stage,  which  is  often  much  prolonged,  unless  the  membranes  are 
punctured  early,  and  the  superabundant  fluid  allowed  to  escape. 

Treatment. — No  treatment  is  known  to  have  any  effect  on  the 
disease.  If  the  discomfort  and  distension  are  very  great,  it  may  be 
absolutely  necessary  to  puncture  the  membranes,  and  allow  the  w^ater 
to  escape.  This  inevitably  brings  on  labor.  If  the  pregnancy  be 
not  sufficiently  advanced  to  give  hope  for  the  birth  of  a  living  child, 
we  would  not,  of  course,  resort  to  this  expedient  unless  the  mother's 
health  was  seriously  imperilled.  It  is  possible  that  in  such  cases  the 
patient  might  be  relieved  by  inserting  the  minute  needle  of  an  aspi- 
rator through  the  os,  and  removing  a  certain  quantity  of  the  liquor 
amnii  by  aspiration,  without  inducing  the  labor.  I  have  never  had 
an  opportunity  of  trying  this  expedient,  but  it  seems  a  possibility. 

Deficiency  of  Liquor  Amnii. — A  defective  amount  of  liquor  amnii 
is  said  to  favor  certain  malformations,  by  allowing  the  uterus  to 
compress  the  foetus  unduly.  It  certainly  occasionally  gives  rise  to 
adhesion  between  the  foetus  and  the  membranes,  and  to  the  formation 
of  amniotic  bands  which  are  capable  of  producing  certain  foetal  de- 
formities (p.  227). 

Appearance  of  the  Liquor  Amnii. — The  liquor  amnii  itself  varies 
much  in  appearance.  It  is  sometimes  thick  and  treacly,  instead  of 
limpid,  arid  it  may  be  offensive  in  odor.  The  cause  of  these  varia- 
tions is  not  well  understood. 

Pathology  of  the  Foztus. — There  is  abundant  evidence  that  the  foetus 
in  utero  is  subject  to  many  diseases,  some  of  which  cause  its  death, 
and  others  leave  distinct  traces  of  their  existence,  although  not 
proving  fatal.  The  subject  is  of  great  importance,  and  is  well  worthy 
of  study.  There  is  still  much  to  be  done  in  this  direction,  which 
may  yet  lead  to  important  practical  results.  I  can,  however,  do  little 
more  than  enumerate  some  of  the  principal  affections  which  have 
been  observed. 

I$lood  Diseases  transmitted  through  the  Mother.  Smallpox. — It  is  a 
well-established  fact  that  the  various  eruptive  fevers,  from  which 
the  mother  may  suffer,  may  be  communicated  to  the  foetus  in  utero. 
When  the  mother  is  attacked  with  confluent  smallpox,  she  almost 
always  aborts,  but  not  necessarily  so  when  it  is  discrete  or  modified. 
In  such  cases  it  has  often  happened  that  the  foetus  has  been  born 


224  PREGNANCY. 

with  evident  marks  of  smallpox.  Cases  are  on  record  which  prove 
that  the  foetus  was  attacked  subsequently  to  the  mother.  Thus  a 
mother  attacked  with  smallpox  has  miscarried,  and  has  given  birth 
to  a  living  child  showing  no  trace  of  the  disease,  which,  however, 
showed  itself  in  two  or  three  days;  proving  that  it  had  been  con- 
tracted, and  had  run  through  its  usual  period  of  incubation,  when 
the  foetus  was  still  in  utero.  It  does  not  follow,  however,  that  the 
foetus  is  affected,  as  Sarres  has  collected  22  cases  in  which  women, 
suffering  from  smallpox,  gave  birth  to  children  who  had  not  con- 
tracted the  disease.  It  has  been  supposed  that,  in  such  cases,  the 
child  is  protected  from  small-pox,  though  it  has  shown  no  symptom 
of  having  had  the  disease.  Tarnier,  however,  cites  two  instances  in 
which  such  children  had  smallpox  two  years  after  birth.  Madge 
and  Simpson  record  cases  in  which  vaccination  performed  on  the 
mother  during  pregnancy  protected  the  foetus,  on  whom  all  subse- 
quent attempts  at  vaccination  failed.  There  is  evidence  also  to 
prove  that  the  disease  may  be  transmitted  to  the  foetus  through  a 
mother,  who  is  herself  unsusceptible  of  contagion;  the  child  having 
been  covered  with  smallpox  eruption,  the  mother  being  quite  free 
from  it.  It  is  probable,  that  the  same  facts  which  have  been  ob- 
served with  regard  to  smallpox,  hold  true  with  reference  to  other 
zymotic  diseases,  such  as  scarlet  fever  and  measles,  although  there  is 
not  sufficient  evidence  to  justify  a  positive  assertion  to  that  effect. 

Meashs  and  Scarlet  Fever. — Amongst  other  maternal  diseases,  mala- 
rious and  lead  poisoning  are  known  to  affect  the  foetus  in  utero.  Dr. 
Stokes  relates  cases  in  which  the  mother  suffered  from  tertian  ague, 
the  child  having  also  attacks,  as  evidenced  by  its  convulsive  move- 
ments, appreciable  by  the  mother,  which  took  place  at  the  regular 
intervals,  but  at  a  different  time  from  the  mother's  paroxysms.  In 
other  cases  the  febrile  paroxysm  comes  on  at  the  same  time  in  the 
foetus  as  in  the  mother;  and  the  fact  has  been  verified  by  the  observa- 
tion that  the  paroxysms  continued  to  recur  simultaneously  after 
delivery.  The  foetus  has  also  been  born  with  distinct  malarious 
enlargement  of  the  spleen.  From  the  frequency  with  which  largely 
hypertrophied  spleens  are  seen  in  mere  infants  in  malarious  districts, 
I  imagine  that  the  intra-uterine  disease  must  be  common.  I  have 
frequently  observed  this  fact  in  India,  although,  of  course,  without 
any  possibility  of  ascertaining  if  the  mothers  had  suffered  from  inter- 
mittent fever  during  pregnancy.  Lead-poisoning  is  also  known  to 
have  a  most  prejudicial  effect  on  the  foetus,  and  frequently  to  lead  to 
abortion.  M.  Paul  has  collected  81  cases,1  in  which  it  caused  the 
death  of  the  foetus,  in  some  not  until  after  birth;  and  occasionally  it 
seems  to  have  affected  the  foetus  even  when  the  mother  escaped. 

Syphilis. — Of  all  blood  dyscrasioe  transmitted  to  the  foetus,  the 
most  important  is  syphilis.  Its  influence  in  producing  repeated 
abortion  has  been  elsewhere  described.  It  may  unquestionably  be 
transmitted  to  the  fcetus  without  producing  abortion,  and  at  term 
the  mother  may  be  either  delivered  of  a  living  child,  bearing  evi- 

1  Arch.  G6n.  de  Mfed.,  1860. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  225 

dent  traces  of  the  disease ;  of  a  dead  cliild  similarly  affected ;  or  of 
an  apparently  healthy  child  in  whom  the  disease  develops  itself 
after  a  lapse  of  a  month  or  two.  These  varying  effects  probably  de- 
pend on  the  intensity  of  the  poison.  The  disease  is,  no  doubt,  gen- 
erally transmitted  through  the  mother,  and  if  she  be  affected  at  the 
time  of  conception,  the  infection  of  the  foetus  seems  certain.  If, 
however,  she  contracts  the  disease  at  an  advanced  period  of  preg- 
nancy the  child  may  entirely  escape.  Ricord  even  believes  that 
syphilis,  contracted  after  the  six  months  of  pregnancy,  never  affects 
the  child.  The  father  alone  may  transmit  the  disease  to  the  ovurn  ; 
and  Hutchinson  has  recorded  cases  to  show  that  the  mother  may  be- 
come secondarily  affected  through  the  diseased  foetus.  The  evi- 
dences of  syphilitic  taint  in  a  living  or  dead  child  are  sufficiently 
characteristic.  The  child  is  generally  puny  and  ill-developed.  An 
eruption  of  pemphigus  is  common,  either  fully  developed  bullee,  or 
their  early  stage,  when  they  form  circular  copper-colored  patches. 
This  eruption  is  always  most  marked  on  the  hands  and  feet,  and  a 
child  born  with  such  an  eruption  may  be  certainly  considered  sphi- 
litic.  On  post-mortem  examination  the  most  usual  signs  are  small 
patches  of  suppuration  in  the  thymus,  similar  localized  suppurations 
in  the  tissues  of  the  lungs,  indurated  yellowish  patches  in  the  liver, 
and  peritonitis,  the  importance  of  which  in  causing  the  death  of 
syphilitic  children  has  been  specially  dwelt  on  by  Simpson.1 

Inflammatory  Diseases. — The  most  important  of  the  inflammatory 
diseases  affecting  the  foetus  is  peritonitis.  Simpson  has  shown  that 
traces  of  it  are  very  frequently  met  with,  and  that  it  is  not  always 
syphilitic.  Sometimes  it  has  been  observed  when  the  mother  has 
been  in  bad  health  during  pregnancy,  and  at  others  it  seems  to  have 
resulted  from  some  morbid  condition  of  the  foetal  viscera.  Pleurisy, 
with  effusion,  is  another  inflammatory  affection  which  has  been 
noticed. 

Dropsies. — The  dropsical  affections  most  generally  met  with  are 
ascites  and  hydrocephalus,  which  may  both  have  the  effect  of  im- 
peding delivery.  Of  these  hydrocephalus  is  the  more  common,  and 
may  give  rise  to  much  difficulty  in  labor.  Its  causes  are  uncertain 
but  it  probably  depends  on  some  altered  state  of  the  mother's  health, 
as  it  is  apt  to  recur  in  several  successive  pregnancies,  and  is  not  in- 
frequently associated  with  an  imperfectly  developed  vertebral  column 
and  spina  bifida.  The  fluid  collects  in  the  ventricles,  which  it 
greatly  distends,  and  these  then  produce  expansion  and  thinning  of 
the  cranium,  the  bones  of  which  are  widely  separated  from  each 
other  at  the  sutures,  which  are  prominent  and  fluctuating.  In  a 
few  cases  internal  hydrocephalus  may  be  complicated,  and  the  diag- 
nosis in  labor  consequently  obscured,  by  the  coexistence  of  what 
has  been  called  "  external  hydrocephalus."  This  consists  of  a  collec- 
tion of  fluid  between  the  skull  and  the  scalp,  which  may  be  either 
formed  there  originally,  or  may  collect  from  a  rupture  of  one  of  the 
sutures  or  fontanelles  during  labor,  through  which  the  mtra-cranial 
fluid  escapes. 

1  Obst.  Works,  vol.  i.  p.  117. 


22G 


PREGNANCY. 


Ascites  is  generally  associated  with  hydramnios,  and  sometimes 
with  hydro-thorax,  or  other  dropsical  effusions.  Tt  is  a  rare  affec- 
tion, and,  according  to  Depaul,1  extreme  distension  of  the  bladder  is 
not  infrequently  mistaken  for  it. 

Tumors  of  different  kinds  may  be  met  with  in  various  parts  of  the 
child's  body,  which  sometimes  grow  to  a  great  size  and  impede  de- 
livery. Tarnier  records  cases  of  meningocele  larger  than  a  child's 
head,  and  large  cystic  growths  have  been  observed  attached  to  the 
nates,  pectoral  region,  or  other  parts  of  the  body.  Cancerous  tumors 
of  considerable  size,  either  external,  or  of  the  viscera,  have  also  been 
met  with.  Other  foetal  tumors  may  be  produced  by  congenital  de- 
formities, such  as  projection  of  the  liver  or  other  abdominal  viscera 
through  a  deficiency  of  the  abdominal  wall ;  or  spina  bifida,  from 
imperfectly  developed  vertebrae.  The  amount  of  dystocia  produced 
by  such  causes  will,  of  course,  vary  much  in  proportion  to  the  size, 
consistency,  and  accessibility  of  the  tumor. 

Wounds  and  Injuries  of  the  Foetus. — Accidents  of  serious  gravity 
to  the  foetus  may  happen  from  violence,  to  which  the  mother  has 
been  subjected,  such  as  falls  or  blows,  without  necessarily  interfering 
with  gestation.  Many  curious  examples  of  this  kind  are  on  record. 
Thus  a  child  has  been  born  presenting  a  severe  lacerated  wound,  ex- 
tending the  whole  length  of  the  spine,  where  both  the  skin  and  the 
muscles  had  been  torn,  and  which  seems  to  have  resulted  from  the 
mother  having  fallen  in  the  last  month  of  pregnancy.  Similar 
lacerations  and  contusions  have  been  observed  in  other  parts  of  the 
body,  the  wounds  being  in  various  stages  of  cicatrization,  corre- 
sponding to  the  lapse  of  time  since  the  acci- 
dent had  occurred.  Intra-uterine  fractures 
are  not  rare,  apparently  arising  from  similar 
causes.  In  some  of  these  cases  the  broken 
ends  of  the  bones  had  united,  but,  from  want 
of  accurate  apposition,  at  an  acute  angle,  so 
as  to  give  rise  to  much  subsequent  de- 
formity. Chaussier  records  two  cases  in 
which  there  were  many  fractures  in  the 
same  child,  in  one  113,  and  in  another  42, 
which  were  in  different  stages  of  repair.  He 
attributes  this  curious  occurrence  to  some 
congenital  defect  in  the  nutrition  of  the 
bones,  possibly  allied  to  mollities  ossium.2 

Intra-uterine  amputations  of  fatal  limbs 
have  not  infrequently  been  observed. 
Children  are  occasionally  born  with  one  ex- 
tremity more  or  less  completely  absent,  and 
cases  are  known  in  which  the  whole  four 
extremities  were  wranting  (Fig.  88.)  The 

mode  in  which  these  malformations  are  produced  has  given  rise  to 
much  discussion.     At  one  time  it  was  supposed  that  the  deficiency 


FIG. 


Intra-uterine   Amputation  of  both 
Arms  and  Legs. 


1  Tarnier's  Cazeaux,  p.  855. 


2  Gazette  Hebdom.,  1860. 


PATHOLOGY    OF    THE    DECIDUA    AND    OVUM.  227 

of  the  limb  was  due  to  gangrene  of  the  extremity,  and  subsequent 
separation  of  the  sphacelated  parts.  Reuss,  who  has  studied  the 
whole  subject  very  minutely,1  considers  gangrene  in  the  unruptured 
ovum  to  be  an  impossibility,  for  that  change  cannot  occur  unless 
there  is  access  of  oxygen,  and  when  portions  of  the  separated  ex- 
tremity are  found  in  utero,  as  is  often  the  case,  they  show  evidences 
of  maceration,  but  not  of  decomposition.  The  general  belief  is  that 
these  intra-uterine  amputations  depend  on  constriction  of  the  limb 
by  folds  or  bands  of  the  amnion — most  often  met  with  when  the 
liquor  amnii  is  deficient  in  quantity— which  obstruct  the  circulation, 
and  thus  give  rise  to  atrophy  of  the  part  below  the  constriction.  It 
has  been  supposed  that  the  umbilical  cord  might,  by  encircling  the 
limb,  produce  a  like  result.  It  appears  doubtful,  however,  whether 
this  cause  is  sufficient  to  produce  complete  separation  of  the  limb,  as 
any  great  amount  of  constriction  would  interfere  with  the  circulation 
through  the  cord.  Sometimes,  when  intra-uterine  amputation  occurs, 
the  separated  portion  of  the  limb  is  found  lying  loose  in  the  amniotic 
cavity,  and  is  expelled  after  the  child.  Cases  of  this  kind  have  been 
recorded  by  Martin,  Chaussier,  and  Watkinson.  More  often  no  trace 
of  the  separated  extremity  can  be  found.  The  explanation  probably 
depends  upon  the  period  of  utero-gestation  at  which  amputation  took 
place.  If  it  occurred  at  a  very  early  period  of  pregnancy,  before  the 
third  month,  the  detached  portion  would  be  minute  and  soft,  and 
would  easily  disappear  by  solution.  If  at  a  later  period,  this  could 
hardly  happen,  and  the  detached  portion  would  remain  in  utero.  In 
cases  of  the  latter  kind  cicatrization  of  the  stump  has  often  been  ob- 
served to  be  incomplete.  Simpson  pointed  out  the  occasional  exist- 
ence of  rudimentary  ringers  or  toes  on  the  stump  of  an  amputated 
limb,  such  as  are  seen  on  the  thighs  in  Fig.  88.  These  he  attributed 
to  an  abortive  reproduction  of  the  separated  extremity,  analogous  to 
what  is  observed  in  some  of  the  lower  animals.  This  explanation 
has  been  contested  with  much  show  of  reason.  Martin  believes  that 
the  reproduction  is  only  apparent,  and  that  the  rudimentary  ex- 
tremities are,  in  reality,  instances  of  arrested  development.  The 
constricting  agents  interfered  with  the  circulation  sufficiently  to 
arrest  the  growth  of  the  limb  below  the  site  of  constriction,  but  not 
sufficiently  to  effect  complete  separation.  If  constriction  occurred 
at  a  very  early  stage  of  development  an  appearance  similar  to  that 
observed  by  Simpson  would  be  produced.  It  does  not  follow,  how- 
ever, that  all  cases  of  absence  of  limbs  depend  on  intra-uterine  ampu- 
tations. In  some  cases  they  would  appear  to  be  the  result  of  a  sponta- 
neous arrest  of  development,  or  of  congenital  monstrosity.  Mr.  Scott2 
relates  a  case  in  which  a  distinct  hereditary  tendency  was  evident, 
and  here  the  deformity  certainly  could  not  have  resulted  from  the 
constriction  of  amniotic  bands.  In  this  family  the  grandfather  had 
both  forearms  wanting,  with  rudimentary  fingers  attached  ;  the  next 
generation  escaped ;  but  the  grandchild  had  a  deformity  precisely 
similar  to  the  grandfather. 

'  Scanzoni's  Beitrage,  1869  2  Obstet.  Trans.,  vol.  xiii.  p.  94. 


228  PREGNANCY. 

Death  of  Foetus. — When,  from  any  cause,  the  foetus  has  died  during 
pregnancy,  it  may  either  be  soon  expelled,  or  it  may  be  retained  in 
utero  for  a  longer  or  shorter  time,  or  even  to  the  full  period.  The 
changes  observed  in  such  foetuses  vary  considerably  according  to  the 
age  of  the  foetus  at  the  time  of  death,  or  the  time  that  it  has  been 
retained  in  utero.  If  it  die  at  an  early  period,  when  the  tissues  are 
very  soft,  it  may  entirely  dissolve  in  the  liquor  amnii,  and  no  trace 
of  it  may  be  found  when  the  membranes  are  expelled.  Or  it  may 
shrivel  or  mummify;  and  if  this  happen  in  a  twin  pregnancy,  as 
sometimes  occurs,  the  growing  foetus  may  compress  and  flatten  the 
dead  one  against  the  uterine  wall. 

Appearance. — At  a  later  period  of  pregnancy  a  dead  foetus  under- 
goes changes  ascribed  to  putrefaction,  but  which  produce  appearances 
different  from  those  of  decomposition  in  animal  textures  exposed  to 
the  atmosphere.  There  is  no  offensive  smell,  as  in  ordinary  decay. 
The  tissues  are  all  softened  and  flaccid.  The  more  manifest  changes 
are  in  the  skin,  the  epidermis  of  which  is  separated  from  the  cutis 
vera,  which  has  a  deep  reddish  color.  This  is  especially  apparent  on 
the  abdomen,  which  is  flaccid,  and  hollow  in  the  centre.  The  internal 
organs  are  much  altered.  The  brain  is  diffluent  and  pulpy,  and  the 
cranial  bones  loose  within  the  scalp.  The  structures  of  the  muscles 
and  viscera  are  in  various  stages  of  transformation,  many  having 
undergone  fatty  changes,  and  containing  crystals  of  margarin  and 
cholesterin.  The  extent  to  which  these  changes  occur  depends,  to  a 
great  extent,  on  the  length  of  time  the  foetus  has  been  dead,  but  they 
do  not  admit  of  our  estimating  with  any  degree  of  accuracy  what  that 
time  has  been. 

The  symptoms  and  diagnosis  of  the  death  of  the  foetus  may  here  be 
considered.  They  are,  unfortunately,  not  very  reliable.  The  cessa- 
tion of  the  foetal  movements  cannot  be  depended  on,  as  they  are 
frequently  unfelt  for  days  or  weeks,  when  the  child  is  alive  and  well. 
Sometimes  the  death  of  the  foetus  is  preceded  by  its  irregular  and 
tumultuous  movements,  and,  in  women  who  have  been  delivered  of 
several  dead  children  in  succession,  this  sensation  may  guide  us  in 
our  diagnosis.  This  suspicion  may  be  confirmed  by  auscultation. 
The  mere  fact  that -we  are  unable,  at  any  given  time,  to  hear  the 
foetal  heart  will  not  justify  an  opinion  that  the  foetus  is  dead.  If, 
however,  the  foetal  heart  has  been  distinctly  heard,  and  after  one  or 
two  careful  examinations,  repeated  at  separate  times,  it  cannot  again 
be  made  out,  the  probability  of  the  child  being  dead  may  be  assumed. 
Certain  changes  in  the  mother's  health  have  been  noted  in  connection 
with  the  death  of  the  foetus,  such  as  depression  and  lowness  of  spirits, 
a  feeling  of  coldness  and  weight  about  the  lower  parts  of  the  abdomen, 
paleness  of  the  face,  a  livid  circle  round  the  eyes,  irregular  shiverings 
and  feverishness,  shrinking  of  the  breasts,  and  diminution  in  the  size 
of  the  abdominal  tumor.  All  these,  however,  are  too  indefinite  to 
justify  a  positive  diagnosis,  and  they  are  not  infrequently  altogether 
absent.  At  most  they  can  do  no  more  than  cause  a  suspicion  as  to 
what  has  happened. 


ABORTION    AND    PREMATURE    LABOR.  229 


CHAPTER  X. 

ABORTIOX  AXD  PREMATURE  LABOR. 

Importance  and  Frequency  of  Abortion. — The  premature  expulsion 
of  the  foetus  is  an  event  of  great  frequency.  The  number  of  foetal 
lives  thus  lost  is  enormous.  There  are  few  multipart  who  have  not 
aborted  at  one  time  or  other  of  their  lives.  Ilegar  estimates  that 
about  one  abortion  occurs  to  every  8  or  10  deliveries  at  term.  White- 
head  has  calculated  that  at  least  90  per  cent,  of  married  women,  who 
lived  to  the  change  of  life,  had  aborted.  The  influence  of  this  acci- 
dent on  the  future  health  of  the  mother  is  also  of  great  importance. 
It  rarely,  indeed,  proves  directly  fatal,  but  it  often  produces  great 
debility  from  the  profuse  loss  of  blood  accompanying  it ;  and  it  is 
one  of  the  most  prolific  causes  of  uterine  disease  in  after  life,  possibly 
because  women  are  apt  to  be  more  careless  during  convalescence  than 
after  delivery,  and  the  proper  involution  of  the  uterus  is  thus  more 
frequently  interfered  with. 

Definition. — A  not  uncommon- division  of  the  subject  is  into  abor- 
tion, miscarriage,  and  premature  labor,  the  first  name  being  applied 
to  expulsion  of  the  ovum  before  the  end  of  the  fourth  month  of  utero- 
gestation  ;  miscarriage  to  expulsion  from  the  end  of  the  fourth  to  the 
end  of  the  sixth  month ;  and  premature  labor  to  expulsion  from  the 
end  of  the  sixth  month  to  the  term  of  pregnancy.  This  is,  however, 
a  needless  and  confusing  subdivision,  which  leads  to  no  practical 
result.  It  suffices  to  apply  the  term  abortion  or  miscarriage  indis- 
criminately to  all  cases  in  which  pregnancy  is  terminated  before  the 
foetus  has  arrived  at  a  viable  age,  and  premature  labor  to  those  in 
which  there  is  a  possibility  of  its  survival.  There  is  little  or  no 
hope  of  a  foetus  living  before  the  28th  week  or  seventh  lunar  month, 
and  this  period  is  therefore  generally  fixed  on  as  the  limit  between 
premature  labor  and  abortion.  The  rule  is,  however,  not  without 
an  occasional,  although  very  rare,  exception.  Dr.  Keiller,  of  Edin- 
burgh, has  recorded  an  instance  in  which  a  foetus  was  born  alive  at 
the  fourth  month,  nine  days  after  the  mother  had  experienced  the 
sensation  of  quickening.  I  myself  recently  attended  a  lady  who  mis- 
carried in  the  fifth  month  of  pregnancy,  the  child  being  born  alive, 
and  living  for  three  hours.  Several  cases  are  on  record  in  which 
after  delivery  at  the  sixth  month  the  child  survived,  and  was  reared. 
The  possibility  of  the  birth  of  a  living  child  under  such  circum- 
stances should  be  recognized,  at  it  may  give  rise  to  legal  questions 
of  importance ;  but  the  exceptions  to  the  ordinary  rule  are  so  rare, 
that  they  need  not  interfere  with  the  division  of  the  subject  usually 
made. 


230  PREGNANCY. 

Abortion  is  most  Common  in  Multipart. — Multipart  abort  far  more 
frequently  than  primiparse.  This  is  contrary  to  the  statement  in  many 
obstetrical  works.  Thus,  Tyler  Smith  says  "there  seems  to  be  a 
greater  danger  of  this  accident  in  the  first  pregnancy."  Schroeder,1 
however,  states  that  23  multipart  abort  to  3  priiniparae;  and  Dr. 
Whitehead,  of  Manchester,  who  has  particularly  studied  the  subject, 
believes  that  abortion  is  more  apt  to  occur  after  the  third  and  fourth 
pregnancies,  especially  when  these  take  place  towards  the  time  for 
the  cessation  of  menstruation. 

Liability  to  a  recurrence  of  Abortion. — There  can  be  no  doubt  that 
women  who  have  aborted  more  than  once  are  peculiarly  liable  to  a 
recurrence  of  the  accident.  This  can  generally  be  traced  to  the  exist- 
ence of  some  predisposing  cause  which  persists  through  several  preg- 
nancies, as,  for  example,  a  syphilitic  taint,  a  uterine  flexion,  or  a 
morbid  state  of  the  lining  membrane  of  the  uterus.  It  is  probable 
that  in  many  women  a  recurrence  of  the  accident  induces  a  habit 
of  abortion,  or,  perhaps  it  might  be  more  accurate  to  say,  a  peculiar 
irritable  condition  of  the  uterus,  which  renders  the  continuance  of 
pregnancy  a  matter  of  difficulty,  independently  of  any  recognizable 
organic  cause. 

Very  early  Abortions  are  often  Unrecognized. — The  frequency  of 
abortion  varies  much  at  different  periods  of  pregnancy;  and  it  occurs 
much  more  often  in  the  early  months,  because  of  the  comparatively 
slight  connection  -then  existing  between  the  chorion  and  the  decidua. 
At  a  very  early  period  of  pregnancy  the  ovum  is  cast  off  with  such 
facility,  and  is  of  such  minute  size,  that  the  fact  of  abortion  having 
occurred  passes  unrecognized.  Very  many  cases,  in  which  the  patient 
goes  one  or  two  weeks  over  her  time,  and  then  has  what  is  supposed 
to  be  merely  a  more  than  usually  profuse  period,  are  probably  in- 
stances of  such  early  miscarriages.  Velpeau  detected  an  ovum,  of 
about  fourteen  days,  which  was  not  larger  than  an  ordinary  pea,  and 
it  is  easy  to  understand  how  so  small  a  body  should  pass  unnoticed 
in  the  blood  which  esdapes  along  with  it. 

Abortions  before  the  Third  Month  and  between  the  Third  and  Sixth. 
—Up  to  the  end  of  the  third  month,  when  miscarriage  occurs,  the 
ovum  is  generally  cast  off  en  masse,  the  decidua  subsequently  coming 
away  in  shreds,  or  as  an  entire  membrane.  The  abortion  is  then 
comparatively  easy.  From  the  third  to  the  sixth  month,  after  the 
placenta  is  formed,  the  amnion  is,  as  a  rule,  first  ruptured  by  the 
uterine  contractions,  and  the  foetus  is  expelled  by  itself.  The  pla- 
centa and  membranes  may  then  be  shed  as  in  ordinary  labor.  It 
often  happens,  however,  that  on  account  of  the  firmness  of  the  pla- 
cental  adhesion  at  this  period,  the  secundines  are  retained  for  a 
greater  or  less  length  of  time.  This  subjects  the  patient  to  many 
risks,  especially  to  those  of  profuse  hemorrhage,  and  of  septicaemia. 
For  this  reason,  premature  termination  of  the  pregnancy  is  attended 
by  much  greater  danger  to  the  mother  between  the  third  and  sixth 
months,  than  at  an  earlier  or  later  date.  After  the  sixth  month  the 

1  Schroeder,  Manual  of  Midwifery,  p.  149. 


ABORTION    AND    PREMATURE    LABOR.  231 

course  of  events  is  not  different  from  that  attending  ordinary  labor. 
The  prognosis  to  the  child  is  more  unfavorable  in  proportion  to  the 
distance  from  the  full  period  of  gestation  at  which  premature  labor 
takes  place. 

Causes. — The  causes  of  abortion  may  conveniently  be  subdivided 
into  the  predisposing  and  excitiny,  the  latter  being  often  slight,  and 
such  as  would  have  no  effect  in  inducing  uterine  contractions  in 
women  unless  associated  with  one  or  more  of  the  former  class  of 
causes.  The  predisposition  to  abortion  may  depend  on  some  condi- 
tion interfering  with  the  vitality  of  the  ovum,  or  its  relation  to  the 
maternal  structures,  or  on  certain  conditions  directly  affecting  the 
mother's  health. 

Causes  referable  to  the  Foetus. — One  of  the  most  common  antece- 
dents of  abortion  is  the  death  of  the  foetus,  which  leads  to  secondary 
changes,  and  ultimately  produces  the  uterine  contractions  which  end 
in  its  expulsion.  The  precise  causes  of  death  in  any  given  case  cannot 
always  be  accurately  ascertained,  as  they  sometimes  depend  on  con- 
ditions which  are  traceable  to  the  maternal  structures,  at  others  to 
the  ovular,  or,  it  may  be,  to  a  combination  of  the  two.  Nor  does  it 
by  any  means  follow  that  the  death  of  the  ovum  immediately  results 
in  its  expulsion.  The  mode  in  which  death  of  the  ovum  produces 
abortion  is  not  difficult  to  understand,  for  it  necessarily  leads  to 

FIG.  89. 


An  Apoplectic  Ovum,  with  Blood  effused  in  Masses  under  the  Fatal  Surface  of  the  Membrane. 

changes  in  the  relations  between  the  ovular  and  maternal  structures; 
these  changes  cause  hemorrhages — partly  external,  and  partly  into 
the  membranes — which,  in  their  turn,  excite  uterine  contraction. 
Extravasations  of  blood  may  take  place  in  various  positions.  One 


232 


PREGNANCY. 


of  the  most  common  is  into  the  decidual  cavity,  between  the  decidna 
vera  and  the  decidua  reflexa — or  between  the  decidua  vera  and  the 
uterine  walls.  If  the  hemorrhage  is  only  slight,  and  especially  if  it 
comes  from  that  portion  of  the  decidua  near  the  internal  os,  and  at 
a  distance  from  the  ovum,  there  need  be  no  material  separation,  and 
pregnancy  may  continue.  This  explains  the  cases  occasionally  met 
with,  in  which  there  is  more  or  less  hemorrhage,  without  subsequent 
abortion.  "When  the  amount  of  extravasated  blood  is  at  all  groat, 
separation  and  abortion  necessarily  result,  and  the  decidua  will  be 
found  on  expulsion  to  have  coagula  on  its  surface,  and  between  its 
various  layers  which  are  found  to  project  into  the  cavity  of  the 
amnion  (Fig.  89).  In  other  cases  hemorrhage  is  still  more  extensive, 
and,  after  breaking  through  the  decidua  reflexa,  it  forms  clots  between 
it  and  the  chorion,  and  even  in  the  cavity  of  the  amnion.  Supposing 
expulsion  to  take  place  shortly  after  coagula  are  deposited  among  the 
membranes,  the  blood  is  little  altered,  and  we  have  an  ordinary 
abortion.  If,  however,  the  ovum  is  retained,  the  coagulated  fibriue, 
and  the  placenta  or  membranes,  undergo  secondary  changes,  which 
lead  to  the  formation  of  moles.  The  so-called  fleshy  mole  (Fig.  90) 

FIG.  90. 


Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Jlemhrane. 

is  often  retained  for  many  weeks  or  months  after  the  death  of  the 
foetus,  and  during  this  time  there  may  be  but  little  modification  of 
the  usual  symptoms  of  pregnancy;  or,  as  is  frequently  the  c;i 
gives  rise  to  occasional  hemorrhage,  until  at  last  uterine  contractions 
come  on,  and  it  is  cast  off'  in  the  form  of  a  thick  fleshy  mass,  having 
but  little  resemblance  to  the  ordinary  products  of  conception.  The 
most  probable  explanation  of  its  formation  is,  that  when  hemorrhage 
originally  took  place,  the  effusion  of  blood  was  not  sufficient  to  effect 


ABORTION    AND    PREMATURE    LABOR.  233 

the  entire  separation  and  expulsion  of  the  ovum.  Part  of  the  mem- 
branes, or  of  the  plaeenta — -if  that  organ  had  commenced  to  form — 
retained  its  organic  connection  with  the  uterus,  while  the  foetus 
perished.  The  attached  portion  of  the  placenta  or  membranes  con- 
tinues to  be  nourished,  although  abnormally.  The  foetus  generally 
entirely  disappears,  especially  if  it  has  perished  at  an  early  period  of 
utero-gestation,  when  it  becomes  dissolved  in  the  liquor  amnii.  Or 
it  may  become  macerated,  shrivelled,  and  greatly  altered  in  appear- 
ance. The  effused  blood  becomes  decolorized  from  the  absorption 
of  the  corpuscles;  and,  according  to  Scanzoni,  fresh  vessels  are 
developed  in  the  fibrine,  which  increase  the  vascular  attachment  of 
the  mole  to  the  uterine  walls.  The  placenta  and  membranes  may 
go  on  increasing  in  thickness,  until  they  form  a  mass  of  considerable 
size.  Careful  microscopic  examination  will  almost  always  enable  us 
to  discover  the  villi  of  the  chorion,  altered  in  appearance,  often  loaded 
with  granular  fatty  molecules,  but  sufficiently  distinct  to  be  readily 
recognizable. 

Causes  depending  on  the  Maternal  State. — Important  as  are  the 
causes  of  abortion  arising  from  some  morbid  condition  of  the  ovum, 
they  are  not  more  so  than  those  which  depend  on  the  maternal  state, 
and  it  is  to  be  observed  that  the  former  are  often  indirect  causes, 
produced  by  primary  maternal  changes.  Many  of  these  maternal 
causes  act  by  causing  hyperaamia  of  the  uterus,  which  leads  to  ex- 
travasation of  blood.  Thus  abortion  is  apt  to  occur  in  women  who 
lead  unhealthy  lives,  such  as  those  who  occupy  over-heated  and  ill- 
ventilated  rooms,  or  indulge  to  excess  in  the  fatigues  and  pleasures 
of  society,  in  the  use  of  alcoholic  drinks,  and  the  like.  Over-frequent 
coitus  has  been,  for  the  same  reason,  observed  to  produce  a  remark- 
able tendency  to  abortion,  and  Parent-Duchatelet  has  noted  that  it 
is  of  very  frequent  occurrence  amongst  women  of  loose  life.  Many 
diseases  strongly  predispose  to  it,  such  as  fevers,  zymotic  diseases 
of  all  kinds,  measles,  scarlet  fever,  smallpox ;  and  diseases  of  the 
respiratory  organs,  such  as  bronchitis  and  pneumonia.  Syphilis  is 
well  known  to  be  one  of  the  most  frequent  causes,  and  one  that  is 
likely  to  act  in  successive  pregnancies.  It  may  act  so  that  the  preg- 
nancy is  brought  to  a  premature  termination,  time  after  time,  until 
the  constitutional  disease  is  eradicated  by  appropriate  treatment. 
It  acts  in  some  cases  through  the  influence  of  the  father  in  producing 
a  diseased  ovum  ;  and  it  is  the  only  cause  which  can  with  certainty 
be  traced  to  the  state  of  the  father's  health.  Many  other  morbid 
conditions  of  the  blood  also  dispose  to  abortion.  It  has  been  observed 
to  be  a  frequent  result  of  lead-poisoning ;  also  of  the  presence  of 
noxious  gases  in  the  atmosphere,  such  as  an  excess  of  carbonic  acid. 

Catises  acting  through  the  Nervous  System. —  Many  causes  act 
through  the  nervous  system,  such  as  fright,  anxiety,  sudden  shock, 
and  the  like.  Thus  there  are  numerous  instances  on  record  in  which 
women  aborted  suddenly  after  the  receipt  of  some  bad  news,  and  it 
is  said  to  have  been  of  frequent  occurrence  in  women  immediately 
before  execution.  The  influence  of  irritations  propagated  through 
the  nervous  system  from  a  distance,  tending  to  produce  uterine  con- 
16 


234  PREGNANCY. 

traction  and  abortion  through  the  agency  of  reflex  action,  has  been 
specially  dwelt  upon  by  Tyler  Smith.  Tims  he  points  out  that  abor- 
tion not  unfrequently  occurs  from  the  irritation  of  constant  suckling, 
in  women  who  become  pregnant  during  lactation.  The  effect  of  suck- 
ling in  producing  uterine  contraction  is,  indeed,  well  known,  and  the 
application  of  the  child  to  the  breast,  for  this  purpose,  has  long  been 
recognized  as  a  method  of  treatment  in  post-partum  hemorrhage. 
The  irritation  of  the  trifacial  in  severe  toothache  ;  of  the  renal  nerves 
in  cases  of  gravel,  in  albuminuria,  etc. ;  of  the  intestinal  nerves  in 
excessive  vomiting,  in  diarrhoea,  obstinate  constipation,  ascarides, 
etc.,  all  act  in  the  same  way.  We  may,  perhaps,  also  explain,  by 
this  hypothesis,  the  fact,  that  women  are  more  apt  to  abort  at  what 
would  have  been  the  menstrual  epoch,  than  at  other  times,  as  the 
ovarian  nerves  may  then  be  subject  to  undue  excitement.  It  is  prob- 
able, however,  that  there  may  be  also  at  these  times  more  or  less 
active  congestion  of  the  decidua,  which  may  predispose  to  laceration 
of  its  capillaries  and  blood  extravasation.  Such  congestion  exists  in 
those  exceptional  cases  in  which  menstruation  continues  for  one  or 
more  periods  after  conception,  the  blood  probably  escaping  from  the 
space  between  the  decidua  vera  and  reflexa ;  and,  therefore,  there  is 
110  reason  to  question  its  also  happening  even  when  such  abnormal 
menstruation  is  not  present. 

Physical  Causes. — Certain  physical  causes  may  produce  abortion 
by  separating  the  ovum.  Thus  it  may  follow  a  fall,  a  blow,  or  other 
accidents  of  a  trivial  character.  On  the  other  hand,  women  may  be 
subjected  to  injuries  of  the  severest  kind  without  aborting.  The 
probability,  therefore,  is  that  these  apparently  trivial  causes  only 
operate  in  women  who,  for  some  other  reason,  are  predisposed  to  the 
accident.  This  is  borne  out  by  the  fact — which  is  well  known  in 
these  days,  when  the  artificial  production  of  abortion  is,  unhappily, 
far  from  a  very  rare  event — that  it  is  by  no  means  easy  to  destroy 
the  vitality  of  the  foetus.  I  myself  know  of  a  case,  in  which  the 
uterine  sound  was  passed  several  times  into  a  pregnant  uterus  with- 
out producing  abortion,  the  pregnancy  proceeding  to  term.  Oldham 
has  related  a  similar  case  in  which  he  in  vain  attempted  to  induce 
abortion  by  the  sound  in  a  case  of  contracted  pelvis ;  and  Duncan 
has  mentioned  an  instance  in  which  an  mtra-uterine  stem  pessary 
was  unwittingly  introduced,  and  worn  for  some  time  by  a  pregnant 
woman,  without  any  bad  effect.  The  fact  that  pregnancy  is  with 
difficulty  interfered  with  when  there  is  a  healthy  relation  between 
the  ovum  and  the  uterus,  no  doubt,  explains  the  disastrous  effects  of 
criminal  abortion,  which  have  been  especially  insisted  on  by  many 
of  our  American  brethren. 

Causes  depending  on  Morbid  States  of  the  Uterus. — Morbid  states  of 
the  uterus  have  an  important  influence  in  the  production  of  abortion. 
Any  condition  which  mechanically  interferes  with  the  proper  develop- 
ment of  the  uterus  is  apt  to  operate  in  this  way.  Amongst  these 
may  be  mentioned  fibroid  tumors;  the  presence  of  old  peritoneal 
adhesions,  rendering  the  womb  a  more  or  less  fixed  organ ;  but, 
above  all,  flexion  and  displacement  of  the  uterus.  Retroflexion  of 


ABORTION  AND  PREMATURE  LABOR.  235 

the  uterus  is,  unquestionably,  one  of  the  most  frequent  factors  in  its 
production,  not  only  on  account  of  the  irritation  which  the  abnormal 
position  sets  up,  but  from  interference  with  the  uterine  circulation, 
which  leads  to  the  effusion  of  blood,  and  the  death  of  the  ovum. 
An  inflamed  condition  of  the  cervical  and  uterine  mucous  mem- 
branes will  act  in  the  same  way,  should  pregnancy  have  occurred ; 
although  such  a  condition  more  often  prevents  conception  taking- 
place. 

Symptoms. — One  of  the  earliest  indications  of  impending  abortion 
is  more  or  less  hemorrhage.  This  may  at  first  be  slight,  and  may 
last  for  a  short  time  only,  recurring  after  an  interval  of  time ;  or  it 
may  commence  with  a  sudden  and  profuse  discharge.  Occasionally 
it  is  very  abundant,  and  its  continuance  and  amount  form  one  of  the 
gravest  symptoms  of  the  accident.  After  the  loss  of  blood  has  con- 
tinued for  a  greater  or  less  length  of  time — it  may  be  even  for  some 
days — uterine  contractions  come  on,  recurring  at  regular  intervals, 
and  eventually  lead  to  the  expulsion  of  the  ovum.  More  rarely  the 
impending  miscarriage  commences  with  pains,  which. lead  to  lacera- 
tion of  vessels  and  hemorrhage. 

When  Pain  and  Hemorrhage  coexist. — As  long  as  one  or  other  of 
these  symptoms  exists  alone,  we  may  hope  to  avert  the  threatened 
miscarriage;  but  when  both  occur  together  there  is  little  or  no 
chance  of  its  being  arrested.  Certain  premonitory  symptoms  are  de- 
scribed by  authors  as  common  in  abortion,  such  as  feverishness, 
shivering,  a  sensation  of  coldness ;  all  of  which  are  obscure  and  un- 
reliable, and  are  certainly  much  more  frequently  absent  than  present. 

If  the  pregnancy  be  early  it  is  probable  that  the  entire  ovum  will 
be  shed  with  little  trouble,  and  it  often  passes  unperceived  in  the 
clots  which  surround  it.  It  is,  therefore,  of  importance  that  all  the 
discharges  should  be  very  carefully  examined.  After  the  second 
month  the  rigid  and  undilated  cervix  presents  a  formidable  obstacle 
to  the  escape  of  the  ovum,  and  it  may  be  a  considerable  time  before 
there  is  sufficient  dilatation  to  admit  of  its  passage.  This  is  gradually 
effected  by  the  continuance  of  pains,  but  not  without  a  severe  loss  of 
blood.  It  may  be  that  the  amnion  is  ruptured,  and  the  foetus  ex- 
pelled first.  After  a  lapse  of  time  the  secundiries  are  also  shed,  but 
there  may  be  a  considerable  delay,  amounting  even  to  days,  before 
this  is  effected.  [If  the  secundines  are  not  expelled  entire,  a  small 
black  remnant  or  several  portions  may  remain,  as  we  have  seen 
lately,  for  a  month,  the  expulsion  being  preceded  by  a  discharge  of 
blackish  blood,  and  by  constitutional  symptoms,  ending  in  a  mild 
phlegmasia  dolens. — ED.]  As  long  as  any  portions  of  the  membranes 
are  retained  in  utero,  the  patient  is  necessarily  subjected  to  consider- 
able risk,  not  only  from  the  continuance  of  hemorrhage,  but  also  from 
septicaemia.  Hence  it  may  be  laid  down  as  a  rule,  that  we  can  never 
consider  our  patient  out  of  danger  until  we  have  satisfied  ourselves 
that  the  whole  of  the  uterine  contents  have  been  expelled. 

Treatment. — Our  first  endeavor  in  any  case  of  impending  miscar- 
riage will  be,  of  course,  to  avert  the  threatened  accident.  If  hemor- 
rhage has  not  been  excessive,  and  if,  on  vaginal  examination,  which 


236  PREGNANCY. 

should  always  be  practised,  we  find  no  dilatation  of  the  os,  we  may 
entertain  a  reasonable  hope  of  success.  If,  on  the  contrary,  we  find 
the  os  beginning  to  open,  if  we  are  able  to  insert  the  finger  through 
it  so  as  to  touch  the  ovum,  especially  if  pains  also  exist,  we  are 
justified  in  considering  abortion  to  be  inevitable,  and  the  indication 
will  then  be  to  have  the  ovum  expelled,  and  the  case  terminated  as 
soon  as  possible.  In  the  former  case  the  most  absolute  rest  is  the 
first  thing  to  insist  on.  The  patient  should  be,  placed  in  bed,  not 
overburdened  with  clothes,  in  a  cool  temperature,  and  she  should 
have  a  light  and  easily  assimilated  diet.  All  movements,  even  rising- 
out  of  bed  to  empty  the  bladder  or  bowels,  should  be  absolutely  pro- 
hibited. To  avert  the  tendency  to  the  commencement  of  uterine 
contraction  there  is  no  remedy  so  useful  as  opium,  which  must  be 
given  freely,  and  frequently  repeated.  It  may  be  administered  either 
in  the  form  of  laudanum,  or  of  Battley's  sedative  solution,  which  has 
the  advantage  of  producing  less  general  disturbance.  It  may  be 
advantageously  exhibited  in  doses  of  from  20  to  30  minims,  and  re- 
peated after  a  few  hours.  A  still  better  preparation  is  chlorodyne, 
\vhich  I  have  found  of  extreme  value  in  arresting  impending  mis- 
carriage, in  doses  of  15  minims,  repeated  every  third  or  fourth  hour. 
If,  from  any  cause,  it  is  considered  unadvisable  to  give  the  sedative 
by  the  mouth,  it  may  be  administered  in  a  small  starch  enema  per 
rectum.  In  all  cases  it  will  be  necessary  to  keep  the  patient  more  or 
less  under  the  influence  of  the  drug  for  several  days,  and  until  all 
symptoms  of  miscarriage  have  passed  away.  Care  should  be  taken 
that  the  bowels  do  not  become  locked  up  by  the  action  of  the  opiates 
— as  this  might  of  itself  be  a  cause  of  irritation — and  their  constipat- 
ing effects  ought  to  be  obviated  by  small  doses  of  castor  oil,  or  other 
gentle  aperient.  Various  subsidiary  methods  of  treatment  have  been 
recommended,  such  as  bleeding  from  the  arm,  or  the  local  applica- 
tion of  leeches  in  supposed  plethoric  states  of  the  system  ;  revulsives, 
such  as  dry  cupping  to  the  loins ;  the  application  of  ice,  to  check 
hemorrhage;  astringents,  such  as  acetate  of  lead  or  gallic  acid,  for 
the  same  purpose.  Most  of  these,  if  not  hurtful,  will  be,  at  least, 
useless.  The  cases  in  which  venesection  would  be  beneficial  are  ex- 
tremely rare,  and  the  local  applications,  especially  cold,  are  much 
more  apt  to  favor,  than  to  prevent,  uterine  action. 

[  Value  of  Opium. — As  an  instance  of  the  value  of  opium  in  arrest- 
ing abortion  under  unfavorable  circumstances,  we  refer  to  the  follow- 
ing case.  Mrs.  R,  a  young  married  lady  in  affluent  circumstances,  the 
mother  of  two  children,  and  of  apparently  a  phthisical  tendency,  the 
disease  being  in  her  family,  was  taken  in  labor  at  4|  months ;  the 
intermittent  pains  being  very  decided,  and  the  loss  of  blood  con- 
siderable. Under  the  effects  of  morphia  given  at  intervals,  the  pains 
became  gradually  less  frequent  and  severe,  until  at  the  end  of  ten 
hours  they  ceased  entirely.  The  uterine  development  advanced 
without  any  more  interruption,  and  the  patient  gave  birth  to  a  living 
female  child  at  the  end  of  nine  months.  The  foetus  was  a  little  below 
the  average  in  weight,  but  lived. — ED.] 


ABORTION    AND    PREMATURE    LABOR.  237 

Prophylactic  Treatment. — In  cases  of  repeated  miscarriage  in  suc- 
cessive pregnancies,  a  special  course  of  prophylactic  treatment  is 
indicated,  and  is  often  attended  with  much  success.  In  cases  of  this 
kind  the  first  indication,  and  one  which  ought  to  be  carefully  attended 
to,  is  to  seek  for  and,  if  possible,  to  remove  or  mitigate  the  cause 
which  has  given  rise  to  the  former  abortions.  Those  causes  which 
depend  on  constitutional  states  must  first  be  carefully  investigated, 
and  treated  according  to  the  indications  present.  These  may  be 
obscure  and  not  easily  discovered;  but  it  is  certainty  unwise  to 
assume  too  readily  the  existence  of  what  has  been  called  "a  habit  of 
abortion,"  which  further  inquiry  may  prove  to  be  only  an  indication 
of  constitutional  debility,  degeneracy  of  the  placenta!  structures,  or 
a  latent  and  unsuspected  syphilitic  taint.  If  constitutional  debility 
be  present  to  a  marked  extent,  a  generous  diet  and  a  restorative 
course  of  treatment  (preparations  of  iron,  quinine,  and  other  suitable 
tonics),  may  effect  the  desired  object. 

Treatment  in  Cases  depending  on  Local  Causes. — Local  congestion 
of  the  uterus,  or  a  general  plethoric  state  of  the  patient,  have  often 
been  supposed  to  be  efficient  causes  of  recurring  abortion.  Dr.  Henry 
Bennet  has  especially  dwelt  on  the  influence  of  congestion  and  abra- 
sions of  the  cervix  in  causing  premature  expulsion  of  the  foetus,1  and 
recommends  the  topical  application  of  nitrate  of  silver,  or  other 
caustics,  to  the  inflammatory  abrasions  existing  on  the  neck  of  the 
womb.  Formerly  venesection 'was  a  favorite  remedy;  and  many 
authors  have  recommended  the  local  abstraction  of  blood  by  leeches 
applied  to  the  groin,  or  round  the  anus,  or  even  to  the  cervix.  The 
influence  of  general  plethora  is  more  than  doubtful ;  and  although 
local  congestions  are,  probably,  much  more  effective  causes,  still  it 
would  seem  more  judicious  to  treat  them  by  rest,  and  local  sedatives, 
rather  than  by  topical  applications  which,  injudiciously  applied,  might 
produce  the  very  accident  they  were  intended  to  prevent. 

[Advantages  of  a  Pure  Atmosphere. — In  one  plethoric  woman  who 
aborted  repeatedly  in  about  six  weeks  after  impregnation,  and  in 
whom  depletion  failed  and  opium  was  inadmissible  from  cerebral 
disturbance,  we  at  last  succeeded  in  saving  the  foetus.  The  lady 
was  somewhat  rheumatic,  and  subject  to  attacks  of  spasmodic  asthma, 
for  which  she  occasionally  went  to  a  dry  mountainous  region.  Find- 
ing her  pregnant  when  at  this  retreat,  we  kept  her  there  until  she 
had  long  passed  the  usual  time  for  aborting,  when  we  had  her 
brought  home.  During  the  period  from  the  third  to  the  eighth 
month  she  was  at  times  affected  with  uterine  pains,  when  she  was 
kept  still  in  bed  until  they  subsided.  In  the  eighth  and  ninth  months 
there  was  no  trouble,  and  she  was  delivered  at  the  full  period  of 
gestation,  after  having  previously  miscarried  seven  times.  On  one 
occasion,  when  at  home,  we  had  succeeded  in  checking  the  action  of 
the  uterus  until  the  end  of  the  second  month,  but  with  the  effect  of 
producing  such  extreme  prostration,  that  we  were  glad  to  learn  that 
the  foetus  had  been  expelled. — ED.] 

1  On  Inflammation  of  the  Uterus,  p.  432. 


238  PREGNANCY. 

The  position  of  the  uterus  should  be  carefully  investigated.  If  it 
be  found  to  be  retroflexed,  a  well-fitting  Hodge's  pessary  should  be 
applied,  so  as  to  support  it  until  it  has  completely  risen  out  of  the 
pelvis. 

Treatment  in  Cases  depending  on  Syphilis. — The  possibility  of 
syphilitic  infection  should  always  be  inquired  into,  for  this  poison 
may  act  on  the  product  of  conception  long  after  all  appreciable 
traces  of  it  have  disappeared  from  the  infected  parent.  Should  there 
be  recurrent  abortions  in  a  patient  who  had  formerly  suffered  from 
syphilis,  or  whose  husband  had  at  any  time  contracted  the  disease, 
no  time  should  be  lost  in  using  appropriate  anti-syphilitic  remedies, 
which  should  invariably  be  administered  both  to  the  husband  and 
wife.  Diday  especially  insists  that  in  such  cases  it  is  not  sufficient 
to  submit  the  father  and  mother  to  a  mercurial  course  in  the  absence 
of  pregnancy,  but  that,  as  each  successive  impregnation  occurs,  the 
mother  should  again  commence  anti-syphilitic  treatment,  even  though 
she  has  no  visible  traces  of  the  disease.1  In  this  way  there  is  reason- 
able ground  for  hoping  that  infection  of  the  ovum  may  be  prevented. 
I  think,  too,  that  we  may  be  the  more  encouraged  to  persevere  in 
the  treatment  of  these  unfortunate  cases,  from  the  fact  that  the 
syphilitic  poison  tends  to  wear  itself  out.  I  have  seen  several  cases 
in  which  this  taint,  at  first,  produced  early  abortion,  then  each  suc- 
cessive pregnancy  was  of  longer  duration,  until  eventually  a  living 
child  was  born. 

In  fatty  degeneration  of  the  chorion  villi,  and  in  other  morbid  states 
of  the  placenta,  which  act  by  preventing  the  proper  nutrition  of  the 
foetus,  and  the  due  aeration  of  its  blood,  there  is  no  reliable  means 
of  treatment  except  the  general  improvement  of  the  mother's  health. 
Simpson  strongly  recommended  the  administration  of  chlorate  of 
potash  in  cases  in  which  the  child  habitually  dies  in  the  latter 
months  of  pregnancy,  on  the  supposition  that  it  supplied  to  the  blood 
a  large  amount  of  oxygen,  and  thus  made  up  for  any  deficiency  in 
the  supply  of  that  element  through  the  placental  tufts.  The  theory 
is,  at  best,  a  doubtful  one,  although  I  believe  the  drug  to  be  unques- 
tionably beneficial  in  cases  of  the  kind.  It  probably  acts  by  its  tonic 
properties  rather  than  in  the  manner  Simpson  supposed.  It  may  be 
given  in  doses  of  15  to  20  grains  three  times  a  day,  and  may  be 
advantageously  combined  with  small  doses  of  dilute  hydrochloric 
acid.  In  frequently  recurring  premature  labors  with  dead  children, 
Simpson  strongly  recommended  the  induction  of  premature  labor  a 
little  before  the  time  at  which  we  had  reason  to  believe  that  the 
foetus  had  usually  perished;  or,  in  other  words,  before  the  placental 
disease  had  advanced  sufficiently  far  to  interfere  with  its  nutrition. 
The  practice  has  constantly  been  adopted  with  success,  and  is  per- 
fectly legitimate,  but  the  difficulty,  of  course,  is  to  fix  on  the  right 
time.  Careful  auscultation  of  the  foetal  heart  may  be  of  some  use  in 
guiding  us  to  a  decision,  as  the  death  of  the  foetus  is  generally  pre- 

1  Diday,  Infantile  Syphilis,  Syd.  Soc. Trans,  p.  207. 


ABORTION  AND  PREMATURE  LABOR.  239 

ceded  for  some  days  by  irregular,  tumultuous,  and  intermittent 
action  of  the  heart. 

There  will  always  remain  a  certain  number  of  cases  in  winch  no 
appreciable  cause  can  be  discovered.  Under  such  circumstances 
prolonged  rest,  at  least  until  the  time  has  passed  at  which  abortion 
formerly  took  place,  will  afford  the  best  chance  of  avoiding  a  recur- 
rence of  the  accident.  There  must  always  be  some  difficulty  in  car- 
rying out  this  indication,  inasmuch  as  the  patient's  health  is  apt  to 
suffer  in  other  ways  from  the  confinement,  and  the  want  of  fresh  air 
and  exercise  which  it  entails.  The  strictness  with  which  rest  should 
be  insisted  on  must  vary  in  different  cases,  but  it  should  be  specially 
attended  to  at  what  would  have  been  the  menstrual  periods.  At 
these  times  the  patient  should  remain  in  bed  altogether;  at  others 
she  may  lie  on  a  sofa,  and,  if  circumstances  permit,  spend  part  of  the 
day,  at  least,  in  the  open  air.  Sexual  intercourse  should  be  pro- 
hibited. Should  actual  symptoms  of  abortion  come  on,  the  pre- 
ventive treatment,  already  indicated,  may  be  resorted  to.  Great 
care,  however,  should  be  used  in  prescribing  opiates  as  preventives, 
and  they  should  be  given  for  a  specified  time  only.  I  have  seen, 
more  than  once,  an  incurable  habit  of  opium-eating  originate  from 
the  incautious  and  too  long  continued  exhibition  of  the  drug  in 
such  cases. 

When  we  have  satisfied  ourselves  that  abortion  is  inevitable,  we 
must  proceed  to  employ  treatment  that  favors  the  expulsion  of 
the  ovum. 

Removal  of  the  Ovum  when  tvithin  reach. — If  the  os  be  sufficiently 
dilated,  and  the  pains  strong,  we  may  find  the  ovurn  separated  and 
protruding  from  the  os.  We  may  then  be  able  to  detach  it  by  the 
finger.  For  this  purpose  the  uterus  is  depressed  from  without  by 
the  left  hand,  while  an  endeavor  is  made  to  scoop  out  the  ovum  with 
the  examining  finger.  If  it  be  out  of  reach,  and  yet  appears  de- 
tached, chloroform  should  be  administered,  the  whole  hand  intro- 
duced into  the  vagina,  arid  the  finger  into  the  uterine  cavity.  The 
complete  detachment  of  the  ovum  can,  in  this  way,  be  far  more 
readily  and  safely  effected  than  by  using  any  of  the  many  ovum-for- 
ceps which  have  been  invented  for  the  purpose. 

Plugging  of  the  Vagina. — If  the  ovum  be  not  sufficiently  sepa- 
rated, or  the  os  be  undilated,  means  must  be  taken  to  control  the 
hemorrhage  until  the  former  can  be  removed  or  expelled.  It  is  here 
that  plugging  of  the  vagina  finds  its  most  useful  application.  This 
may  be  done  in  various  ways.  That  most  usually  employed  is  filling 
the  vagina  with  a  tolerably  large  sponge,  in  the  interstices  of  which 
the  blood  coagulates.  A  better  plan  is  to  soak  a  number  of  pledgets 
of  cotton- wool  in  water  and  tie  a  string  round  each.  The  vagina  can 
be  completely  and  effectively  packed  with  these ;  and  this  is  best 
done  through  a  speculum.  Each  pledget  should  be  covered  with 
glycerine,  which  completely  prevents  the  offensive  odor  which  other- 
wise always  arises.  The  pledgets  can  be  removed  by  traction  on  the 
strings,  but  if  these  are  not  used  much  pain  is  caused  in  getting  them 
out  of  the  vagina.  The  plug  should  never  be  left  iri  for  more  than 


240  PREGNANCY. 

six  or  eight  hours,  after  which  a  fresh  one  may  be  inserted  if  neces- 
sary. Two  or  three  full  doses  of  the  liquid  extract  of  ergot,  of  3ss 
to  3j  each,  or  a  subcutaneous  injection  of  ergotine,  may  be  given 
while  the  plug  is  in  position.  The  plug  itself  is  a  strong  excitant  of 
uterine  action,  and  the  two  combined  often  effect  complete  detach- 
ment, so  that,  on  the  removal  of  the  tampon,  the  ovum  may  be  found 
lying  loose  in  the  os  uteri.  If  the  os  be  undilated  and  the  ovum  en- 
tirely out  of  reach,  the  former  may  be  opened  by  means  of  sponge  or 
laminaria  tents.  I  think  a  well  prepared  sponge  tent  the  most  ef- 
fectual, and  it  can  be  maintained  in  situ  by  a  vaginal  plug  below  it. 
It  also  acts  as  a  most  efficient  plug,  effectually  controlling  all  hemor- 
rhage. In  a  few  hours  it  opens  up  the  os  sufficiently  to  admit  the 
finger. 

Retention  of  the  Membranes. — The  most  troublesome  cases  are  those 
in  which  the  foetus  is  first  expelled,  and  the  placenta  and  membranes 
remain  in  utero.  As  long  as  this  is  the  case  the  patient  can  never  be 
considered  safe  from  the  occurrence  of  septicaemia.  Dr.  Priestley  has 
strongly  insisted  on  the  importance  of  removing  the  secundines  as 
soon  as  possible.  There  can  be  no  doubt  that  this  should  be  done 
whenever  it  is  feasible.  Cases,  however,  are  frequently  met  with  in 
which  any  forcible  attempt  at  removal  would  be  likely  to  prove  very 
hurtful,  and  in  which  it  is  better  practice  to  control  hemorrhage  by 
the  plug  or  sponge  tent,  and  wait  until  the  placenta  is  detached, 
which  it  will  generally  be  in  a  day  or  two  at  most.  Under  such 
circumstances  fetor  and  decomposition  of  the  secundines  may  be  pre- 
vented by  intra-uterine  injections  of  diluted  Condy's  fluid.  Provided 
the  os  be  sufficiently  patulous  to  prevent  the  collection  of  the  fluid 
in  the  uterine  cavity,  and  not  more  than  a  drachm  or  two  of  fluid  be 
injected  at  a  time,  so  as  simply  to  wash  away  and  disinfect  decom- 
posing detritus,  they  can  be  used  with  perfect  safety.  Sometimes  cases 
are  met  with  in  which  the  os  has  entirely  closed,  and  in  which  we  can 
only  suspect  the  retention  of  the  placenta  by  the  history  of  the  case, 
the  continuance  of  hemorrhage,  or  the  presence  of  a  fetid  discharge. 
Should  we  see  reason  to  suspect  this  the  os  must  be  dilated  with 
sponge  or  lamiuaria  tents,  and  the  uterine  cavity  thoroughly  explored 
under  chloroform.  This  condition  of  things  is  far  from  uncommon 
in  women  who  have  not  had  medical  assistance  from  the  first,  and  it 
often  gives  rise  to  very  troublesome  and  anxious  symptoms.  It  has 
been  said  that  placentae  thus  retained  have  been  completely  absorbed, 
and  cases  of  the  kind  have  been  related  by  Naegele  and  Osiander. 
The  spontaneous  absorption,  however,  of  so  highly  organized  a  body 
as  the  placenta  would  be  a  phenomenon  of  the  most  remarkable 
character ;  and  it  seems  more  natural  to  suppose  that,  in  most  cases 
of  the  kind,  the  placenta  has  been  cast  off'  without  the  knowledge  of 
the  patient.  Sometimes  the  placenta  never  becomes  entirely  de- 
tached, and,  retaining  organic  connection  with  the  uterine  walls, 
forms  what  has  been  called  a  'placental  polypus.'  This  may  produce 
secondary  hemorrhages,  in  the  same  way  as  an  ordinary  fibroid  poly- 
pus. Barnes  recommends  the  removal  of  these  masses  by  means  of 


ABORTION  AND  PREMATURE  LABOR.  241 

the  wire  dcraseur.      Before  their   detection    the  os  uteri   must  be 
opened  up. 

Subsequent  Management. — The  frequency  with  which  abortion  leads 
to  chronic  uterine  disease  should  lead  us  to  attach  much  more  im- 
portance to  the  subsequent  management  of  the  patient  than  has  been 
customary.  The  usual  practice  is  to  confine  the  patient  to  bed  for 
two  or  three  days  only,  and  then  to  allow  her  to  resume  her  ordinary 
avocations,  on  the  supposition  that  a  miscarriage  requires  less  sub- 
sequent care  than  a  confinement.  The  contrary  of  this  is,  however, 
most  probably  the  case ;  for  the  uterus  has  been  emptied  when  it  is 
unprepared  for  involution,  and  that  process  is  often  very  imperfectly 
performed.  We  should,  therefore,  insist  on  at  least  as  much  atten- 
tion being  paid  to  rest  as  after  labor  at  term. 


PART  III. 

LABOR. 


CHAPTER  I. 

THE   PHENOMENA  OF   LABOR. 

Delivery  at  Term. — In  considering  delivery  at  term  we  have  to  dis- 
cuss two  distinct  classes  of  events. 

One  of  these  is  the  series  of  vital  actions  brought  into  play  in 
order  to  effect  the  expulsion  of  the  child ;  and  the  other  consists  of 
the  movements  imparted  to  the  child — the  body  to  be  expelled — in 
other  words,  the  mechanism  of  delivery. 

Causes  of  Labor. — Before  proceeding  to  the  consideration  of  these 
important  topics,  a  few  words  may  be  said  as  to  the  determining 
causes  of  labor.  This  subject  has  been  from  the  earliest  times  a 
qusestio  vexata  among  physiologists ;  and  many  and  various  are  the 
theories  which  have  been  broached  to  explain  the  curious  fact  that 
labor  spontaneously  commences,  if  not  at  a  fixed  epoch,  at  any  rate 
approximately  so.  It  must  be  admitted  that,  even  yet,  there  is  no 
explanation  which  can  be  implicitly  accepted. 

Foetal  or  Maternal  Causes. — The  explanations  which  have  been 
given  may  be  divided  into  two  classes — those  which  attribute  the 
advent  of  labor  to  the  foetus,  and  those  which  refer  it  to  some  change 
connected  with  the  maternal  generative  organs. 

The  former  is  the  opinion  which  was  held  by  the  older  accou- 
cheurs, who  assigned  to  the  foetus  some  active  influence  in  effecting 
its  own  expulsion.  It  need  hardly  be  said  that  such  fanciful  views 
have  no  kind  of  physiological  basis.  Others  have  supposed  that 
there  might  be  some  change  in  the  placental  circulation,  or  in  the 
vascular  system  of  the  foetus,  which  might  solve  the  mystery.  The 
latest  hypothesis  of  this  kind,  which,  however,  is  not  fortified  by  any 
evidence,  is  by  Barnes,  who  says :  "  I  rather  incline  to  the  opinion 
that  when  the  foetus  has  attained  its  full  development,  when  its 
organs  are  prepared  for  external  life,  some  change  takes  place  in  its 
circulation,  which  involves  a  correlative  disturbance  in  the  maternal 
circulation,  which  excites  the  attempt  at  labor."1 

The  majority  of  obstetricians,  however,  refer  the  advent  of  labor 
to  purely  maternal  causes.  Among  the  more  favorite  theories  is  one, 
which  was  originally  started  in  this  country  by  Dr.  Power,  and 
adopted  and  illustrated  by  Depaul,  Dubois,  and  other  writers.  It  is 

1  Diseases  of  Women,  p.  434. 


THE    PHENOMENA    OF    LABOR.  243 

based  on  the  assumption  that  there  is  a  sphincter  action  of  the  fibres 
of  the  cervix,  analogous  to  that  of  the  sphincters  of  the  bladder  and 
rectum,  and  that  when  the  cervix  is  taken  up  into  the  general 
uterine  cavity  as  pregnancy  advances,  the  ovum  presses  upon  it,  irri- 
tates its  nerves,  and  so  sets  up  reflex  action,  which  ends  in  the  estab- 
lishment of  uterine  contraction.  This  theory  was  founded  on  erro- 
neous conceptions  of  the  changes  that  occurred  in  the  neck  of  the 
uterus;  and,  as  it  is  certain  that  obliteration  of  the  cervix  does  not 
really  take  place  in  the  manner  that  Power  believed  when  his  theory 
was  broached,  it  is  obvious  that  its  supposed  result  cannot  follow. 

Distension  of  the  Uterus. — Extreme  distension  of  the  uterus  has 
been  held  to  be  the  determining  cause  of  labor,  a  view  lately  revived 
by  Dr.  King,  of  Washington,1  who  believes  that  contractions  are  in- 
duced because  the  uterus  ceases  to  augment  in  capacity,  while  its 
contents  still  continue  to  increase.  This  hypothesis  is  sufficiently 
disproved  by  a  number  of  clinical  facts  which  show  that  the  uterus 
may  be  subject  to  excessive  and  even  rapid  distension — as  in  cases 
of  hydramnios,  multiple  pregnancy,  and  hydatiform  degeneration  of 
the  ovum — without  the  supervention  of  uterine  contractions. 

Fatty  Degeneration  of  the  Decidua,.- — -Another  incitor  of  uterine 
action  has  been  supposed  to  be  the  separation  of  the  ovum  from  its 
connections  to  the  uterine  parietes,  in  consequence  of  fatty  degenera- 
tion of  the  decidua  occurring  at  the  end  of  pregnancy.  The  sup- 
posed result  of  this  change,  which  undoubtedly  occurs,  is  that  the 
ovum  becomes  so  detached  from  its  organic  adhesions  as  to  be  some- 
what in  the  position  of  a  foreign  body,  and  thus  incites  the  nerves  so 
largely  distributed  over  the  interior  of  the  uterus.  This  theory, 
which  has  been  widely  accepted,  was  originally  started  by  Sir  James 
Simpson,  who  pointed  out  that  some  of  the  most  efficient  means  of 
inducing  labor  (such,  for  example,  as  the  insertion  of  a  gum-elastic 
catheter  between  the  ovum  and  the  uterine  walls)  probably  act  in 
the  same  way,  viz.,  by  effecting  separation  of  the  membranes  and 
detachment  of  the  ovum. 

Barnes  instances,  in  opposition  to  this  idea,  the  fact  that  ineffect- 
ual attempts  at  labor  come  on  at  the  natural  term  of  gestation  in 
cases  of  extra-uterine  pregnancy,  when  the  foetus  is  altogether  inde- 
pendent of  the  uterus,  and  therefore,  he  argues,  the  cause  cannot  be 
situated  in  the  uterus  itself.  A  fair  answer  to  this  argument  would 
be  that  although,  in  such  cases,  the  womb  does  not  contain  the  ovum, 
it  does  contain  a  decidua,  the  degeneration  and  separation  of  which 
might  suffice  to  induce  the  abortive  and  partial  attempts  at  labor 
then  witnessed. 

Objections  to  these  Theories. — A  serious  objection  to  all  these  theories, 
which  are  based  on  the  assumption  that  some  local  irritation  brings 
on  contraction,  is  the  fact,  which  lias  not  been  generally  appreciated, 
that  uterine  contractions  are  always  present  during  pregnancy  as  a 
normal  occurrence,  and  that  they  may  be,  and  often  are,  readily  in- 
tensified at  any  time,  so  as  to  result  in  premature  delivery. 

1  American  Journal  of  Obstetrics,  vol.  iii. 


244  LABOR. 

It  is,  indeed,  most  likely  that,  at  or  about  the  full  term,  the  ner- 
vous supply  of  the  uterus  is  so  highly  developed,  and  in  so  advanced 
a  state  of  irritability,  that  it  more  readily  responds  to  stimuli  than 
at  other  times.  If  by  separation  of  the  decidua,  or  in  some  other 
way,  stimulation  of  the  excitor  nerves  is  then  effected,  more  frequent 
and  forcible  contractions  than  usual  may  result,  and,  as  they  become 
stronger  and  more  regular,  terminate  in  labor.  But,  allowing  this, 
it  still  remains  quite  unexplained  why  this  should  occur  with  such 
regularity  at  a  definite  time. 

Tyler  Smith' 's  Ovarian  Theory. — Tyler  Smith  tried,  indeed,  to  prove 
that  labor  came  on  naturally  at  what  would  have  been  a  menstrual 
epoch,  the  congestion  attending  the  menstrual  nisus  acting  as  the  ex- 
citor of  uterine  contraction.  He,  therefore,  refers  the  onset  of  labor 
to  ovarian,  rather  than  to  uterine,  causes.  Although  this  view  is 
upheld  with  all  its  author's  great  talent,  there  are  several  objections 
to  it  difficult  to  overcome.  Thus,  it  assumes  that  the  periodic  changes 
in  the  ovary  continue  during  pregnancy,  of  which  there  is  no  proof. 
Indeed  there  is  good  reason  to  believe  that  ovulation  is  suspended 
during  gestation,  and  with  it,  of  course,  the  menstrual  nisus.  Be- 
sides, as  has  been  well  objected  by  Cazeaux,  even  if  this  theory  were 
admitted,  it  would  still  leave  the  mystery  unsolved,  for  it  would  not 
explain  why  the  menstrual  nisus  should  act  in  this  way  at  the  tenth 
menstrual  epoch,  rather  than  at  the  ninth  or  eleventh. 

In  spite,  then,  of  the  many  theories  at  our  disposal,  it  is  to  be 
feared  that  we  must  admit  ourselves  to  be  still  in  entire  ignorance  of 
the  reason  why  labor  should  come  on  at  a  fixed  epoch. 

Mode  in  which  the  Expulsion  of  the  Child  is  effected. — The  expulsion 
of  the  child  is  effected  by  the  contractions  of  the  muscular  fibres  of 
the  uterus,  aided  by  those  of  some  of  the  abdominal  muscles.  These 
efforts  are  in  the  main  entirely  independent  of  volition.  So  far  as 
regards  the  uterine  contractions,  this  is  absolutely  true,  for  the 
mother  has  no  power  of  originating,  lessening,  or  increasing  the 
action  of  the  uterus.  As  regards  the  abdominal  muscles,  however, 
the  mother  is  certainly  able  to  bring  them  into  action,  and  to  increase 
their  power  by  voluntary  efforts ;  but,  as  labor  advances,  and  as  the 
head  passes  into  the  vagina  and  irritates  the  nerves  supplying  it,  the 
abdominal  muscles  are  often  stimulated  to  contract,  through  the  influ- 
ence of  reflex  action,  independently  of  volition  on  the  part  of  the 
mother. 

The  Chief  Factor  in  Expulsion. — There  can  be  little  doubt  that  the 
chief  agent  in  the  expulsion  of  the  child  is  the  contraction  of  the 
uterus  itself.  This  opinion  is  almost  unanimously  held  by  accouch- 
eurs, and  the  influence  of  the  abdominal  muscles  is  believed  to  be 
purely  accessory.  Dr.  Haughton,  however,  maintains  a  view  which 
is  directly  contrary  to  this.  From  an  examination  of  the  force  of 
the  uterine  contractions,  arrived  at  by  measuring  the  amount  of  mus- 
cular fibre  contained  in  the  walls  of  the  uterus,  he  arrives  at  the 
conclusion  that  the  uterine  contractions  are  chiefly  influential  in  rup- 
turing the  membranes,  and  dilating  the  os  uteri,  bringing  into  action, 
if  needful,  a  force  equivalent  to  54  Ibs.;  but  when  this  is  effected, 


THE  PHENOMENA  OF  LABOR.  245 

and  the  second  stage  of  labor  has  commenced,  he  thinks  the  remain- 
der of  the  labor  is  mainly  completed  by  the  contractions  of  the  ab- 
dominal muscles,  to  which  he  attributes  enormous  powers,  equivalent, 
if  needful,  to  a  pressure  of  523.65  Ibs.  on  the  area  of  the  pelvic  canal. 

These  views  bear  on  a  topic  of  primary  consequence  in  the  phy- 
siology of  labor.  They  have  been  fully  criticized  by  Duncan,  who 
has  devoted  much  experimental  research  to  the  study  of  the  powers 
brought  into  action  in  the  expulsion  of  the  child.  His  conclusions 
are  that,  so  far  from  the  enormous  force  being  employed  that 
Haughton  estimated,  in  the  large  majority  of  cases  the  effective 
force  brought  to  bear  on  the  child  by  the  combined  action  of  both 
the  uterine  and  abdominal  muscles  is  less  than  50  Ibs. — that  is,  less 
than  the  force  which  Haughton  attributed  to  the  uterus  alone.  In 
extremely  severe  labors,  when  the  resistance  is  excessive,  he  thinks 
that  extra  power  may  be  employed;  but  he  estimates  the  maximum 
as  not  above  80  Ibs.,  including  in  this  total  the  action  of  both  the 
uterine  and  abdominal  muscles.  Joulin  arrived  at  the  conclusion 
that  the  uterine  contractions  were  capable  of  resisting  a  maximum 
force  of  about  one  hundredweight.  Both  these  estimates,  it  will  be 
observed,  are  much  under  that  of  Haughton,  which  Duncan  de- 
scribes as  representing  "a  strain  to  which  the  maternal  machinery 
could  not  be  subjected  without  instantaneous  and  utter  destruction." 

There  are  many  facts  in  the  history  of  parturition  which  make  it 
certain  that  the  chief  factor  in.  the  expulsion  of  the  child  is  the 
uterus.  Among  these  may  be  mentioned  occasional  cases  in  which 
the  action  of  the  abdominal  muscles  is  materially  lessened,  if  not 
annulled — as  in  profound  anaesthesia,  and  in  some  cases  of  para- 
plegia— in  which,  nevertheless,  uterine  contractions  suffice  to  effect 
delivery.  The  most  familiar  example  of  its  influence,  however, 
and  one  that  is  a  matter  of  everyday  observation  in  practice,  is 
when  inertia  of  the  uterus  exists.  In  such  cases  no  effort  on  the 
part  of  the  mother,  no  amount  of  voluntary  action  that  she  can 
bring  to  bear  on  the  child,  has  any  appreciable  influence  on  the 
progress  of  the  labor,  which  remains  in  abeyance  until  the  de- 
fective uterine  action  is  re-established,  or  until  artificial  aid  is 
given. 

The  contraction  of  the  uterus,  then,  being  the  main  agent  in  de- 
livery, it  is  important  for  us  to  appreciate  its  mode  of  action,  and  its 
effect  on  the  ovum. 

Uterine  Contractions  at  the  Commencement  of  Labor. — We  have 
seen  that  intermittent  and  generally  painless  uterine  contractions 
exist  during  pregnancy.  As  the  period  for  delivery  approaches, 
these  become  more  frequent  and  intense,  until  labor  actually  com- 
mences, when  they  begin  to  be  sufficiently  developed  to  effect  the 
opening  up  of  the  os  uteri,  with  the  view  to  the  passage  of  the 
child.  They  are  now  accompanied  by  pain,  which  increases  as  labor 
advances,  and  is  so  characteristic  that  "pains"  are  universally  used 
as  a  descriptive  term  for  the  contractions  themselves.  It  does,  not 
necessarily  follow  that  uterine  contractions  are  painless  until  they 
commence  to  effect  dilatation  of  the  os  uteri.  On  the  contrary, 


246  LABOR. 

during  the  last  days  or  even  weeks  of  pregnancy,  women  constantly 
have  irregular  contractions,  accompanied  by  severe  suffering,  which, 
however,  pass  off'  without  producing  any  marked  effect  on  the  cer- 
vix. When  labor  has  actually  begun,  if  the  hand  is  placed  on  the 
uterus  when  a  pain  commences,  the  contraction  of  its  muscular  tis- 
sue is  very  apparent,  and  the  whole  organ  is  observed  to  become 
tense  and  hard,  the  rigidity  increasing  until  the  pain  has  reached  its 
acme,  the  uterine  walls  then  relaxing,  and  remaining  soft  until  the 
next  pain  comes  on.  At  the  commencement  of  labor  these  pains  are 
few,  separated  from  each  other  by  a  considerable  interval,  and  of 
short  duration.  In  a  perfectly  typical  labor  the  interval  between  the 
pains  becomes  shorter  and  shorter,  while,  at  the  same  time,  the  dura- 
tion of  each  pain  is  increased.  At  first  they  may  occur  only  once  in 
an  hour  or  more,  while  eventually  there  may  not  be  more  than  a  few 
minutes'  interval  between  them. 

Mode  in  ivhich  Dilatation  of  the  Cervix  is  Effected. — If,  when  the 
pains  are  fairly  established,  a  vaginal  examination  be  made,  the  os 
uteri  will  be  found  to  be  thinned  and  dilated  in  proportion  to  the 
progress  of  the  labor.  During  the  contraction  the  bag  of  membranes 
will  be  felt  to  bulge,  to  become  tense  from  the  downward  pressure 
of  the  liquor  amnii  within  it,  and  to  protrude  through  the  os  if  it 
be  sufficiently  open.  The  membranes,  with  the  contained  liquor 
amnii,  thus  form  a  fluid  wedge,  which  has  a  most  important  influence 
in  dilating  the  os  uteri  (see  Frontispiece).  This  does  not,  however, 
form  the  sole  mechanism  by  which  the  os  uteri  is  dilated,  for  it  is 
also  acted  upon  by  the  contractions  of  the  muscular  fibres  of  the 
uterus,  which  tend  to  pull  it  open.  It  is  probable  that  the  muscular 
dilatation  of  the  os  is  effected  chiefly  by  the  longitudinal  fibres,  which, 
as  they  shorten,  act  upon  the  os  uteri,  the  part  where  there  is  least 
resistance. 

Partly  then  by  muscular  contraction,  partly  by  mechanical  pres- 
sure, the  cervical  canal  is  dilated,  and  as  it  opens  up  it,  becomes  thin- 
ner and  thinner,  until  it  is  entirely  taken  up  into  the  uterine  cavity. 

Rupture  of  the  Membranes. — There  is  no  longer  any  obstacle  to  the 
passage  of  the  presenting  part  of  the  child  into  the  cavity  of  the 
pelvis,  and  the  force  of  the  pains  now  generally  effects  the  rupture 
of  the  membranes,  and  the  escape  of  the  liquor  amnii.  There  is 
often  observed,  at  this  time,  a  temporary  relaxation  in  the  frequency 
of  the  pains,  which  had  been  steadily  increasing ;  but  they  soon  re- 
commence with  increased  vigor.  If  the  abdomen  be  now  examined 
it  will  be  observed  to  be  much  diminished  in  size,  partly  in  conse- 
quence of  the  escape  of  the  liquor  amnii,  partly  from  the  descent  of 
the  foetus  into  the  pelvic  cavity. 

Change  in  the  Character  of  the  Pains. — The  character  of  the  pains 
soon  changes.  They  become  stronger,  longer  in  duration,  separated 
by  a  shorter  interval,  and  accompanied  by  a  distinct  forcing  effort, 
being  generally  described  as  "  the  bearing-down"  pains.  Now  is  the 
time  at  which  the  accessory  muscles  of  parturition  come  into  opera- 
tion. The  patient  brings  them  into  play  in  the  manner  which  will 
be  subsequently  described,  and  the  combined  action  of  the  uterine 


THE    PHENOMENA    OF    LABOR.  247 

and  abdominal  muscles  continues  until  the  expulsion  of  the  child  is 
effected. 

Mode  of  Action  of  the  Uterus. — The  precise  mode  of  uterine  con- 
traction is  still  somewhat  a  matter  of  dispute.  It  is  generally  de- 
scribed as  commencing  in  the  cervix,  passing  gradually  upwards  by 
peristaltic  action,  the  wave  then  returning  downwards  towards  the 
os  uteri.  This  view  was  maintained  by  Wigand,  and  has  been  en- 
dorsed by  Eigby,  Tyler  Smith,  and  many  other  writers.  In  support 
of  it  they  instance  the  fact  that,  on  the  accession  of  a  pain,  the  pre- 
senting part  first  recedes,  the  bag  of  membranes  then  becomes  tense 
and  protrudes  through  the  os,  and  it  is  not  until  some  time  that  the 
presenting  part  of  the  child  itself  is  pushed  down.  It  is  very  doubt- 
ful if  this  view  is  correct ;  and  a  careful  examination  of  the  course 
of  the  pains  would  rather  lead  to  the  belief  that  the  contractions 
commence  at  the  fund  us,  where  the  muscular  tissue  is  most  largely 
developed,  and  gradually  proceed  downwards  to  the  cervix ;  the 
waves  of  contraction  being,  however,  so  rapid  that  the  whole  organ 
seems  to  harden  en  masse.  The  apparent  recession  of  the  presenting 
part,  and  the  bulging  of  the  bag  of  membranes,  are  certainly  no 
proof  that  the  contractions  begin  at  the  cervix  ;  for  the  commencing 
contraction  would  necessarily  push  down  the  fluid  in  front  of  the 
head,  and  cause  the  membranes  to  bulge,  and  the  os  to  become  tense, 
before  its  force  was  brought  to  bear  on  the  foetus  itself.  Indeed  did 
the  contraction  commence  at  the  lower  part  of  the  uterus,  we  should 
expect  the  opposite  of  what  takes  place  to  occur,  and  the  waters  to 
be  pushed  upwards,  and  away  from  the  cervix.  The  fundal  origin 
of  the  contraction  is  further  illustrated  by  what  is  observed  when 
the  hand  of  the  accoucheur  is  placed  in  the  uterine  cavity,  as  often 
happens  in  certain  cases  of  hemorrhage  or  turning;  for  if  a  pain 
then  comes  on,  it  will  be  felt  to  start  at  the  fundus,  and  gradually 
compress  the  hand  from  above  downwards. 

Value  of  the  Intermittent  Character  of  the  Pains. — The  intermittent 
character  of  the  contractions  is  of  great  practical  importance.  Were 
they  continuous,  not  only  would  the  muscular  powers  of  the  patient 
be  rapidly  exhausted,  but,  by  the  obliteration  of  the  vessels  produced 
by  the  muscular  contraction,  the  circulation  through  the  placenta 
would  be  interfered  with,  and  the  life  of  the  child  imperilled.  Hence 
one  of  the  chief  dangers  of  protracted  labor,  especially  after  the 
escape  of  the  liquor  amnii,  is  that  the  uterine  fibres  may  enter  into 
a  state  of  tonic  rigidity,  a  condition  that  cannot  be  long  contiuued 
without  serious  risks  both  to  the  mother  and  child. 

The  fact  that  the  uterine  contractions  are  altogether  involuntary 
proves  them  to  be  excited — as  indeed  we  would  a  priori  infer  from 
our  knowledge  of  the  anatomical  arrangement  of  the  nerves  of  the 
uterus— solely  by  the  sympathetic  system.  Still  it  is  a  fact  of  every- 
day observation  that  they  can  be  largely  influenced  by  emotions. 
.Various  stimuli  applied  to  the  spinal  system  of  nerves  (as  for  exam- 
ple when  the  mammae  are  irritated)  have  also  a  marked  effect  in  in- 
ducing uterine  contraction.  The  precise  mode  in  which  such  influ- 
ence is  conveyed  to  the  uterus,  in  spite  of  the  numerous  experiments 


248  LABOR. 

which  have  been  made  for  the  purpose  of  determining  how  far  labor 
is  affected  by  destruction  of  the  spinal  cord,  is  still  a  matter  of  doubt. 
After  the  foetus  has  passed  through  the  cervix,  the  spinal  nerves 
distributed  to  the  vagina  and  perineum  are  excited  by  the  pressure 
of  the  presenting  part,  and,  through  them,  the  accessory  powers  of 
parturition  are  chiefly  brought  into  play.  The  contraction  of  the 
muscles  of  the  vagina  itself  is  supposed  to  have  some  influence  in 
favoring  the  expulsion  of  the  foetus  after  the  birth  of  part  of  the 
body,  and  also  in  promoting  the  expulsion  of  the  placenta.  In  the 
lower  animals  the  vagina  has  a  very  marked  contractile  property, 
and  is,  in  some  of  them,  the  main  agent  by  which  the  young  are 
expelled.  In  the  human  subject  this  influence  is  certainly  of  very 
secondary  importance. 

Character  and  Source  of  Pains  during  Labor. — The  amount  of  suf- 
fering experienced  during  labor  varies  much  in  different  cases,  and 
is  in  direct  proportion  to  the  nervous  susceptibility  of  the  patient. 
There  are  some  women  who  go  through  labor  with  little  or  no  pain 
at  all.  This  is  proved  by  the  cases  (of  which  there  are  numerous 
authentic  instances  recorded)  in  which  labor  has  commenced  during 
sleep,  and  the  child  has  been  actually  born  without  the  mother 
awaking.  I  am  acquainted  with  a  lady,  who  has  had  a  large  family, 
who  assures  me  that,  though  the  labor  is  accompanied  by  a  sense  of 
pressure  and  discomfort,  she  experiences  nothing  which  can  be  called 
actual  pain.  Such  a  happy  state  of  affairs  is,  however,  extremely 
exceptional,  and,  in  the  vast  majority  of  cases,  parturition  is  accom- 
panied by  intense  suffering  during  its  whole  course,  in  some  cases 
amounting  to  anguish,  which  has  probably  no  parallel  under  any 
other  condition. 

The  precise  cause  of  the  pain  has  been  much  discussed,  and  is,  no 
doubt,  complex. 

In  the  First  Stage. — In  the  early  stage  of  labor,  and  before  the  dila- 
tation of  the  os,  it  is  chiefly  seated  in  the  back,  from  whence  it  shoots 
round  the  loins  and  down  the  thighs.  It  is  then  probably  produced, 
partly  by  pressure  on  the  nerve  filaments  caused  by  contraction  of  the 
muscular  fibres  to  which  they  are  distributed,  and  partly  by  stretch- 
ing and  dilatation  of  the  muscular  tissue  of  the  cervix.  M.  Beau 
believes  that  in  this  stage  the  pain  is  not  produced,  strictly  speaking, 
in  the  uterus  itself,  but  is  rather  a  neuralgia  of  the  lumbo-abdominal 
nerves.  The  pains  at  this  time  are  generally  described  as  "acute" 
and  "grinding,"  terms  which  sufficiently  well  express  their  nature. 
In  highly  nervous  women  these  pains  are  often  much  less  well  borne 
than  those  of  a  later  stage,  and  the  suffering  they  undergo  is  indicated 
by  their  extreme  restlessness  and  loud  cries  as  each  contraction 
supervenes.  As  the  os  dilates,  and  the  labor  advances  into  the  ex- 
pulsive stage,  other  sources  of  suffering  are  added. 

In  the  Second  Stage. — The  presenting  part  now  passes  into  the  va- 
gina and  presses  on  the  vaginal  nerves,  as  well  as  on  the  large  ner- 
vous plexuses  lying  in  the  pelvis.  As  it  descends  lower  it  stretches 
the  perineum  and  vulva,  and  presses  on  the  bladder  and  rectum. 
Hence  cramps  are  produced  in  the  muscles  supplied  by  the  nerve 


THE    PHENOMENA    OF    LABOR.  249 

plexuses,  as  well  as  an  intolerable  sense  of  tearing  and  st retelling  in 
the  vulva  and  perineum,  and  often  a  distressing  feeling  of  tenesmus 
in  the  bowels.  13y  this  time  the  accessory  muscles  of  parturition  are 
brought  into  action,  and  they,  as  well  as  the  uterine  muscles,  are 
thrown  into  frequent  and  violent  contractions,  which,  independently 
of  the  other  causes  mentioned,  are  sufficient  of  themselves  to  produce 
great  pain,  likened  to  that  of  colic,  produced  by  involuntary  and 
repeated  contraction  of  the  muscles  of  the  intestines. 

Taking  all  these  causes  into  consideration,  there  is  no  lack  of  suf- 
ficient explanation  of  the  intolerable  suffering  which  is  so  constant 
an  accompaniment  of  child-birth. 

Effect  of  the  Pains  on  the  Mother  and  Foetus. — The  effect  of  the  pains 
on  the  mother's  circulation  is  well  marked.  The  rapidity  of  the  pulse 
increases  distinctly  with  each  contraction,  and,  as  the  pain  passes 
off,  it  again  declines  to  its  former  state.  A  similar  observation  has 
been  made  with  regard  to  the  sounds  of  the  foetal  heart,  especially 
after  the  expulsion  of  the  liquor  amnii.  Hicks  has  pointed  out  that 
during  a  pain  the  muscular  vibrations  give  rise  to  a  sound  which 
often  resembles  that  of  the  foetal  heart,  and  which  completely  disap- 
pears when  the  muscular  tissue  relaxes.  The  effect  of  the  pain  in 
intensifying  the  uterine  souffle  has  been  already  mentioned.  The 
strong  muscular  efforts  would  naturally  lead  us  to  expect  a  marked 
elevation  of  temperature  during  labor.  Further  observations  on  this 
point  are  required ;  but  Squire  asserts  that  there  is  generally  only  a 
very  slight  increase  in  temperature  during  delivery,  rapidly  passing 
off  as  soon  as  labor  is  over. 

Division  of  Labor  into  /Stages. — Such  being  the  physiological  facts- 
in  connection  with  the  labor  pains,  we  may  now  describe  the  ordinary 
progress  of  a  natural  labor — that  is,  one  terminated  by  the  natural 
powers,  and  with  a  head  presenting. 

For  facility  of  description  obstetricians  have  long  been  in  the  habit 
of  dividing  the  course  of  labor  into  stages,  which  correspond  pretty 
accurately  with  the  natural  sequence  of  events.  For  this  purpose 
we  generally  talk  of  three  stages :  viz.,  1,  from  the  commencement 
of  regular  pains  until  the  complete  dilatation  of  the  cervix ;  2,  from 
the  complete  dilatation  of  the  cervix  until  the  expulsion  of  the  child; 
3,  the  concluding  stage,  comprising  the  permanent  contraction  of  the 
uterus,  and  the  separation  and  expulsion  of  the  placenta.  To  these 
we  may  conveniently  add  a  preparatory  stage,  antecedent  to  the 
regular  commencement  of  the  labor. 

Preparatory  Stage. — For  a  short  time  before  delivery,  varying  from 
a  few  days  to  a  week  or  two,  certain  premonitory  symptoms  gene- 
rally exist,  which  indicate  the  approaching  advent  of  labor.  Some- 
times they  are  well  marked,  and  cannot  be  mistaken  ;  .at  others  they 
are  so  slight  as  to  escape  observation.  Amongst  the  most  common 
is  a  sinking  of  the  uterus  into  the  pelvic  cavity,  resulting  from  the 
relaxation  of  the  soft  parts  preceding  delivery.  The  result  is,  that 
the  upper  edge  of  the  uterine  tumor  is  less  high  than  before,  and,  in 
consequence,  the  pressure  on  the  respiratory  organs  is  diminished; 
and  the  woman  often  feels  lighter,  and  altogether  less  unwieldy, 
17 


250  LABOR. 

than  in  the  previous  weeks.  If  a  vaginal  examination  be  made  at 
this  time,  the  lower  segment  of  the  uterus  will  be  found  to  have  sunk 
lower  into  the  pelvic  cavity ;  and  the  consequence  of  this  is  that, 
while  the  respiration  is  less  embarrassed,  and  the  patient  feels  less 
bulky,  other  accompaniments  of  pregnancy,  such  as  hemorrhoids, 
irritability  of  the  bladder  and  bowels,  and  oedema  of  the  limbs,  be- 
come aggravated.  The  increased  pressure  on  the  bowels  often  induces 
a  sort  of  temporary  diarrhoea,  which  is  so  far  advantageous  that  it 
empties  the  bowels  of  faeces  which  may  have  collected  within  them. 
As  has  already  been  pointed  out,  the  contractions  which  have  been 
going  on  at  intervals  during  the  latter  months  of  pregnancy  now  get 
more  and  more  marked,  and  they  have  the  effect  of  producing  a  real 
shortening  of  the  cervix,  which  is  of  great  value  preparatory  to  its 
dilatation.  More  marked  mucous  discharge  from  the  cavity  of  the 
cervix  also  generally  occurs  a  short  time  before  labor,  and  it  is  riot 
infrequently  tinged  with  blood  from  the  laceration  of  minute  capillary 
vessels.  This  discharge,  popularly  known  as  the  "  shows"  is  a  pretty 
sure  sign  that  labor  is  not  far  off.  It  rnay,  however,  be  entirely 
absent,  even  until  the  birth  of  the  child.  When  copious  it  serves  to 
lubricate  the  passages,  and  is  generally  coincident  with  rapid  dilata- 
tion of  the  parts,  and  a  speedy  labor. 

False  Pains. — During  this  time  (premonitory  stage)  painful  uterine 
contractions  are  often  present,  which,  however,  have  no  effect  in 
dilating  the  cervix.  In  some  cases  they  are  frequent  and  severe, 
and  are  very  apt  to  be  mistaken  for  the  commencement  of  real  labor. 
Such  "false pains"  as  they  are  termed,  are  often  excited  and  kept 
up  by  local  irritations,  such  as  a  loaded  or  disordered  state  of  the  in- 
testinal canal ;  and  they  frequently  give  rise  to  considerable  distress, 
and  much  inconvenience  both  to  the  patient  and  practitioner.  They 
are,  it  should  be  remembered,  only  the  normal  contractions  of  the 
uterus,  intensified  and  accompanied  with  pain. 

First  Staye,  or  Dilatation. — As  labor  actually  commences,  the 
uterine  contractions  become  stronger,  and  the  fact  that  they  are 
"  true"  pains  can  be  ascertained  by  their  effect  on  the  cervix.  If  a 
vaginal  examination  be  made  during  one  of  these,  the  membranes 
will  be  felt  to  become  tense  and  bulging  during  the  pain,  and  the  os 
uteri  will  be  found  partially  dilated,  and  thinned  at  its  edges.  As 
labor  advances  this  effect  on  the  os  becomes  more  and  more  marked. 
At  first  the  dilatation  is  very  slight,  perhaps  not  more  than  enough 
to  admit  the  tip  of  the  examining  finger,  and  both  the  upper  and 
lower  orifices  of  the  cervix  can  be  made  out.  As  the  pains  get 
stronger  and  more  frequent,  dilatation  proceeds  in  the  way  already 
described,  and  the  cervix  gets  more  thin  and  tense,  until  we  can  feel 
a  thin  circular  ring  (which  is  lax  between  the  pains,  but  becomes 
rigid  and  tense  during  the  contraction  when  the  bag  of  water  bulges 
through  it),  without  any  distinction  between  the  upper  and  lower 
orifices.  During  this  time  the  patient,  although  she  may  be  suffer- 
ing acutely,  is  generally  able  to  sit  up  and  walk  about.  The  amount 
of  pain  experienced  varies  much  according  to  the  character  of  the 
patient.  In  emotional  women  of  highly-developed  nervous  suscepti- 


THE    PHENOMENA    OF    LABOR.  251 

bilities  it  is  generally  very  great.  They  are  restless,  irritable,  and 
desponding,  and  when  the  pain  conies  on  cry  out  loudly.  The 
character  of  the  cry  is  peculiar  and  well  marked  during  the  first  stage, 
and  has  constantly  been  described  by  obstetric  writers  as  charac- 
teristic. It  is  acute  and  high,  and  is  certainly  very  different  from 
the  deep  groans  of  the  second  stage,  when  the  breath  is  involuntarily 
retained  to  assist  the  parturient  effort.  When  dilatation  is  nearly 
completed  various  reflex  nervous  phenomena  often  show  themselves. 
One  of  these  is  nausea  and  vomiting,  another  is  uncontrollable 
shivering,  which  is  not  accompanied  by  a  sense  of  coldness,  the 
patient  being  often  hot  and  perspiring.  Both  these  symptoms  indi- 
cate that  the  propulsive  stage  will  shortly  commence  ;  and  they  may 
be  regarded  as  favorable  rather  than  otherwise,  although  they  are 
apt  to  alarm  the  patient  and  her  friends.  By  this  time  the  os  is  fully 
dilated,  the  membranes  generally  rupture  spontaneously,  and  a  con- 
siderable portion  of  the  liquor  amnii  flows  away.  The  head,  if  pre- 
senting, often  acts  as  a  sort  of  ball-valve,  and,  falling  down  on  the 
aperture  of  the  cervix,  prevents  the  complete  evacuation  of  the 
liquor  amnii,  which  escapes  by  degrees  during  the  rest  of  the  labor, 
or  may  be  retained  in  considerable  quantity  until  the  birth  of  the 
child. 

It  not  infrequently  happens,  if  the  membranes  are  somewhat 
tougher  than  usual,  and  the  pains  frequent  and  strong,  that  the 
foetus  is  pushed  through  the  pelvis,  and  even  expelled,  surrounded 
by  the  membranes.  When  this  occurs  the  child  is  said  to  be  born 
with  a  "caw?,"  and  this  event  would  doubtless  happen  more  fre- 
quently than  it  does,  were  it  not  the  custom  of  the  accoucheur  to 
rupture  the  membranes  artificially  as  soon  as  the  os  is  completely 
opened  up,  after  which  time  their  integrity  is  no  longer  of  any  value. 

Second  Stage,  or  Propulsion. — The  os  is  now  entirely  retracted  over 
the  presenting  part,  and  is  no  longer  to  be  felt,  the  vagina  and  the 
uterine  cavity  forming  a  single  canal.  Now  the  mucous  discharge  is 
generally  abundant,  so  that  the  examining  finger  brings  away  long 
strings  of  glairy  transparent  rnucus,  tinged  with  blood.  The  pains, 
after  a  short  interval  of  rest,  become  entirely  altered  in  character. 
The  uterus  contracts  tightly  round  the  foetus,  the  presenting  part  de- 
scends into  the  pelvis,  and  the  true  propulsive  pains  commence.  The 
accessory  muscles  of  parturition  now  come  into  play.  With  each 
pain  the  patient  takes  a  deep  inspiration,  and  thus  fills  the  chest,  so 
as  to  give  a  point  cTappui  to  the  abdominal  muscles.  For  the  same 
reason  she  involuntarily  seizes  hold  of  some  point  of  support,  as  the 
hand  of  a  bystander  or  a  towel  tied  to  the  bed,  and,  at  the  same  time 
pushes  with  her  feet  against  the  end  of  the  bed,  and  so  is  able  to 
bear  down  to  advantage.  The  cries  are  no  longer  sharp  and  loud, 
but  consist  of  a  series  of  deep  suppressed  groans,  which  correspond 
to  a  succession  of  short  expirations  made  during  the  straining  effort. 
In  this  way  the  abdominal  muscles  contract  forcibly  on  the  uterus, 
which  they  further  stimulate  to  action  by  pressing  upon  it.  It  is  to 
be  observed  that  these  straining  efforts  are,  to  a  considerable  extent, 
under  the  control  of  the  patient.  By  encouraging  her  to  hold  her 


252  LABOR. 

breath  and  bear  down  they  can  be  intensified ;  while  if  we  wish  to 
lessen  them  we  can  advise  her  to  call  out,  and  when  she  does  so  the 
abdominal  muscles  have  no  longer  a  fixed  point  of  action.  Although 
the  patient  may  thus  lessen  the  effect  of  these  accessory  muscles,  it 
is  entirely  out  of  her  power  to  stop  their  action  altogether.  As  labor 
advances  the  head  descends  lower  and  lower,  receding  somewhat  in 
the  intervals  between  the  pains,  until  eventually  it  comes  down  on 
the  perineum,  which  it  soon  distends. 

Distension  of  the  Perineum  and  Birth  of  the  Child. — The  pains  now 
get  stronger  and  more  frequent,  often  with  scarcely  a  perceptible  in- 
terval between  them,  until  the  perineum  gets  stretched  by  the  ad- 
vancing head.  In  the  interval  between  the  pains  elasticity  of  the 
perineal  structures  pushes  the  head  upwards,  so  as  to  diminish  the 
tension  to  which  the  perineum  is  subjected,  the  next  pain  again  put- 
ting it  on  the  stretch,  and  protruding  the  head  a  little  further  than 
before.  By  this  alternate  advance  and  recession,  the  gradual  yield- 
ing of  the  structures  is  favored,  and  risk  of  laceration  greatly  dimin- 
ished. During  this  time  the  pressure  of  the  head  mechanically 
empties  the  bowel  of  its  contents.  During  the  last  pains,  when  the 
perineum  is  stretched  to  the  utmost,  the  anal  aperture  is  dilated, 
sometimes  to  the  size  of  a  five-shilling  piece ;  and  in  this  way  the 
perineum  is  relaxed,  just  as  the  distension,  and  consequent  risk  of 
laceration,  are  at  their  maximum.  The  apex  of  the  head  now  pro- 
trudes more  and  more  through  the  vulva,  surrounded  by  the  orifice 
of  the  vagina,  and  eventually  it  glides  over  the  perineum  and  is 
expelled.  The  intensity  of  the  suffering  at  this  moment  generally 
causes  the  patient  to  call  out  loudly.  The  force  of  the  abdominal 
muscles  is  thus  lessened  at  the  last  moment,  and  this,  in  combination 
with  the  relaxation  of  the  sphincter  ani,  forms  an  admirable  con- 
trivance for  lessening  the  risk  of  perineal  injury.  The  rest  of  the 
body  is  generally  expelled  immediately  by  a  single  pain,  and  with  it 
are  discharged  the  remains  of  the  liquor  amnii,  and  some  blood- clots 
from  separation  of  the  placenta ;  and  so  the  second  stage  of  labor 
terminates. 

The  Third  Stage.  Its  Importance. — The  third  stage  commences 
after  the  expulsion  of  the  child.  It  is  of  paramount  importance  to 
the  safety  of  the  mother  that  it  should  be  conducted  in  a  natural 
and  efficient  manner ;  for  it  is  now  that  the  uterine  sinuses  are  closed, 
and  the  frail  barrier  by  which  nature  effects  this  may  be  very  readily 
interfered  with,  and  serious  and  even  fatal  loss  of  blood  ensue.  Un- 
fortunately, it  is  too  often  the  case  that  the  practitioner's  entire  at- 
tention is  fixed  on  the  expulsion  of  the  child,  so  that  the  natural 
history  of  the  rest  of  delivery  is  very  generally  imperfectly  studied 
and  understood. 

•  Contraction  of  the  Uterus  and  Detachment  of  the  Placenta. — As  soon 
as  the  child  is  expelled,  the  uterine  fibres  contract  in  all  directions, 
and  the  hand,  following  the  uterus  down,  will  find  that  it  forms  a 
firm  rounded  mass  lying  in  the  lower  part  of  the  abdominal  cavity. 
By  retraction  of  its  internal  surface,  the  placenta!  attachments  are 


THE    PHENOMENA    OF    LABOR. 


253 


FIG. 91. 


generally  separated,  and  the  after-birth  remains  in  the  cavity  of  the 
uterus  as  a  foreign  body. 

Mode  in  ichich  Hemorrhage  is  Prevented. — The  escape  of  blood  from 
the  open  mouths  of  the  uterine  sinuses  is  now  prevented  in  two  ways: 
viz.,  (1)  by  the  contraction  of  the  uterine  walls,  and  the  more  firm, 
persistent,  and  tonic  this  is,  the  more  certain  is  the  immunity  from 
hemorrhage;  (2)  by  the  formation  of  coagula  in  the  mouths  of  the 
vessels.  Any  undue  haste  in  promoting  the  expulsion  of  the  pla- 
centa tends  to  prevent  the  latter  of  these  two  hemostatic  safeguards, 
and  is  apt  to  be  followed  by  loss  of  blood.  After  a  certain  time, 
averaging  from  a  quarter  to  half  an  hour,  the  uterus  will  be  felt  to 
harden,  and,  if  the  case  be  solely  left  to  nature,  what  has  been  aptly 
called  a  miniature  labor  occurs.  Pains  come  on,  and  the  placenta  is 
spontaneously  expelled  from  the  uterus,  either  into  the  canal  of  the 
vagina,  or  even  externally.  In  most  obstetric  works  it  is  stated  that 
the  after-birth  may  be  separated  either  from  its  centre  or  edge,  and 
that  it  is  very  generally  expelled  through  the  os 
in  an  inverted  form,  with  itsfostal  surface  down- 
wards, and  folded  transversely  on  itself.  That 
this  is  the  mode  in  which  the  placenta  is  often 
expelled,  when  traction  on  the  cord  is  practised, 
is  a  matter  of  certainty.  It  then  passes  through 
the  os  very  much  in  the  shape  of  an  inverted 
umbrella.  It  is  certain,  however,  that  this  is 
not  the  natural  mechanism  of  its  delivery. 
What  this  is  has  been  well  illustrated  by  Dun- 
can,1 who  has  very  clearly  shown  that,  when  this 
stage  of  labor  is  left  entirely  to  nature,  the  sepa- 
rated placenta  is  expelled  edgeways,  its  uterine 
and  detached  surface  gliding  along  the  inner  sur- 
face of  the  uterus,  the  foldings  of  its-  structure 
being  parallel  to  the  long  diameter  of  the  uter- 
ine cavity  (Fig.  91).  In  this  way  it  is  expelled 
into  the  vagina,  and  during  the  process  little  or 
no  hemorrhage  occurs.  When  the  placenta  is 
drawn  out  in  the  way  too  generally  practised,  it 
obstructs  the  aperture  of  the  os,  and,  acting  like 
the  piston  of  a  pump,  tends  to  promote  hemorrhage.  The  corol- 
laries as  to  treatment  drawn  from  these  facts  will  be  subsequently 
considered.  I  am  anxious,  however,  here  to  direct  attention  to  na- 
ture's mechanism,  because  I  believe  there  is  no  part  of  labor  about 
the  management  of  which  erroneous  views  are  more  prevalent  than 
that  of  this  stage,  and  none  in  which  they  are  more  apt  to  lead  to 
serious  consequences ;  and  unless  the  mode  in  which  nature  effects 
the  expulsion  of  the  placenta,  and  prevents  hemorrhage,  is  thoroughly 
understood,  we  shall  certainly  fail  in  assisting  her  in  a  proper  man- 
ner. In  the  large  proportion  of  cases,  when  left  entirely  to  them- 
selves, the  placenta  would  be  retained,  if  not  in  the  uterus,  at  any  rate 


Mode  in  which  the  Placenta 

is  Naturally  Expelled. 

(After  Duncan.) 


1   Edin.  Med.  Jour.,  April,  1871. 


254  LABOR. 

in  the  vagina,  for  a  considerable  time — possibly  for  several  hours — 
and  such  delay  would  very  unnecessarily  tire  the  patience  of  the 
practitioner,  and  be  prejudicial  to  the  patient.  It  is,  therefore,  our 
duty  in  the  majority  of  cases,  to  promote  the  expulsion  of  the  after- 
birth ;  and  when  this  is  properly  and  scientifically  done,  we  increase, 
rather  than  diminish  the  patient's  safety  and  comfort.  But,  in  order 
to  do  this,  we  must  assist  nature,  and  not  act  in  opposition  to  her 
method,  as  is  so  often  the  case. 

After-pains. — When  once  the  placenta  is  expelled,  the  uterus  con- 
tracts still  more  firmly,  and,  in  a  typical  case,  is  felt  just  within  the 
pelvic  brim,  hard  and  firm,  and  about  the  size  of  a  cricket  ball. 
Generally  for  several  hours,  or  even  for  one  or  two  days,  it  occasion- 
ally relaxes  and  contracts,  and  these  contractions  give  rise  to  the 
"  after-pains''1  from  which  women  often  suffer  much.  The  object  of 
these  pains  is,  no  doubt,  to  expel  any  coagula  that  may  remain  in 
the  uterus,  and  therefore,  however  unpleasant  they  may  be  to  the 
patient,  they  must  be  considered,  unless  very  excessive,  to  be  salutary 
rather  than  otherwise. 

Duration  of  Labor. — The  length  of  labor  varies  extremely  in  dif- 
ferent cases,  and  it  is  quite  impossible  to  lay  down  any  definite  rules 
with  regard  to  it.  Subject  to  exceptions,  labor  is  longer  in  primi- 
parae  than  in  multipart,  on  account  of  the  greater  resistance  of  the 
soft  parts  in  the  former,  especially  of  the  structures  about  the  vagina 
and  vulva.  It  is  also  generally  stated  that  the  difficulty  of  labor 
increases  with  the  age  of  the  patient,  and  that  in  elderly  primiparge 
it  is  likely  to  be  unusually  tedious  from  rigidity  of  the  soft  parts. 
It  is  very  doubtful  if  this  opinion  has  any  real  basis,  and  in  such 
cases  the  practitioner  often  finds  himself  agreeably  disappointed  on 
the  result.  Mr.  Roper,1  indeed,  argues  that  the  wasting  of  the  tissues 
which  occurs  after  forty  years  of  age  diminishes  their  resistance,  and 
that  first  labors,  after  that  age,  are  easier,  as  a  rule,  than  in  early 
life.  The  habits  and  mode  of  life  of  patients  have,  no  doubt,  a  con- 
siderable influence  on  the  duration  of  labor,  but  we  are  not  in  posses- 
sion of  any  very  reliable  facts  with  regard  to  this  subject.  It  is 
reasonable  to  suppose  that  the  tissues  of  large,  muscular,  strongly 
developed  women  will  offer  more  resistance  than  those  of  slighter 
build.  On  the  other  hand,  women  of  the  latter  class,  especially  in 
the  upper  ranks  of  life,  more  often  develop  nervous  susceptibilities, 
which  may  be  expected  to  influence  the  length  of  their  labors.  The 
average  duration  of  labor,  calculated  from  a  large  number  of  cases, 
is  from  eight  to  ten  hours;  even  in  primiparae,  however,  it  is  con- 
stantly terminated  in  one  or  two  hours  from  its  commencement,  and 
may  be  extended  to  twenty-four  hours  without  any  symptoms  of 
urgency  arising.  In  multipart  it  is  frequently  over  in  even  a  shorter 
time.  Indications  calling  for  interference  may  arise  at  any  time 
during  the  progress  of  labor,  independently  of  its  length.  The  pro- 
portion between  the  length  of  the  first  and  second  stages  also  varies 
considerably.  The  first  stage  is  generally  the  longest ;  and  it  is 

5  Obst.  Trans.,  v.  7. 


DELIVERY    IN    HEAD    PRESENTATIONS.  ZOO 

stated  by  Cazeaux  to  be  normally  about  twice  the  length  of  the 
second.  This  is  probably  under  the  mark,  and  I  believe  Joulin  to 
be  nearer  the  truth  in  stating  that  the  iirst  stage  should  be  to  the 
second  as  four  or  five  to  one,  rather  than  as  two  to  one.  Often  when 
the  first  stage  has  been  very  prolonged,  the  second  is  terminated 
rapidly. 

Necessity  of  Caution  in  expressing  an  Opinion  as  to  the  possible 
Duration  of  Labor. — -The  practitioner  is  constantly  asked  as  to  the 
probable  length  of  labor,  and  the  uncertainty  of  this  should  always 
lead  him  to  give  a  most  guarded  opinion.  Even  when  labor  is  pro- 
gressing apparently  in  the  most  satisfactory  manner,  the  pains  fre- 
quently die  away,  and  delivery  may  be  delayed  for  many  hours.  In 
the  first  stage  a  cervix  that  is  apparently  rigid  and  unyielding  may 
rapidly  and  unexpectedly  dilate,  and  delivery  soon  follow.  In  either 
case,  if  the  practitioner  has  committed  himself  to  a  positive  opinion 
he  is  apt  to  incur  blame,  and  it  is  far  better  always  to  be  extremely 
cautious  in  our  predictions  on  this  point. 

Period  of  the  Day  at  which  Labor  Occurs. — A  somewhat  larger  pro- 
portion of  deliveries  occur  in  the  early  hours  of  the  morning  than  at 
other  times.  Thus  West1  found  that  out  of  2019  deliveries,  780  took 
place  from  11  P.M.  to  7  A.M.,  662  from  7  A.M.  to  3  P.M.,  and  577 
from  3  P.M.  to  11  P.M. 


CHAPTER  II. 

MECHANISM    OF    DELIVERY   IN   HEAD   PRESENTATIONS. 

Importance  of  the  /Subject. — It  is  quite  impossible  to  over-estimate 
the  importance  of  thoroughly  understanding  the  mechanism  of  the 
passage  of  the  foetus  through  the  pelvis.  This  dominates  the  whole 
scientific  practice  of  midwifery,  and  the  practitioner  cannot  acquire 
more  than  a  merely  empirical  knowledge,  such  as  may  be  possessed 
by  any  uneducated  midwife,  or  to  conduct  the  more  difficult  cases 
requiring  operative  interference,  with  safety  to  the  patient  or  satis- 
faction to  himself,  unless  he  thoroughly  masters  the  subject. 

In  treating  of  the  physiological  phenomena  of  labor,  it  was 
assumed  that  we  had  to  do  with  an  ordinary  case  of  head  presenta- 
tion, the  description  being  applicable,  with  slight  variations,  to  pre- 
sentations of  other  parts  of  the  foetus.  So  in  discussing  the  mechanical 
phenomena  of  delivery,  I  shall  describe  more  in  detail  the  mechanism 
of  head  presentation,  reserving  any  account  of  the  mechanism  of 
other  presentations  until  they  are  separately  studied.  Head  presen- 

1  Amer.  Med.  Journ.,  1854. 


256  LABOR. 

tation  is  so  much  more  frequent  than  that  of  any  other  part — 
amounting  to  95  per  cent,  of  all  cases — that  this  mode  of  studying 
the  subject  is  fully  justified;  and,  when  once  the  student  has  mastered 
the  phenomena  of  delivery  in  head  presentations,  he  will  have  little 
difficulty  in  understanding  the  mechanism  of  labor  when  other  parts 
of  the  foetus  present,  based,  as  it  always  is,  on  the  same  general  plan. 

Position  of  the  Head  by  its  Sutures  and  Fontanelles. — In  entering  on 
this  study  we  come  to  appreciate  the  importance  of  the  sutures  and 
fontanelles  in  enabling  us  to  detect  the  position  of  the  foetal  head, 
and  to  watch  its  progress  through  its  canal;  and  unless  the  "tactus 
eruditus"  by  which  these  can  be  distinguished  from  each  other  has 
been  acquired,  the  practitioner  will  be  unable  to  satisfy  himself  of 
the  exact  progress  of  the  labor.  Nor  is  this  always  easy.  Indeed, 
it  requires  considerable  experience  and  practice  before  it  is  possible 
to  make  out  the  position  of  the  head  with  absolute  certainty;  but 
this  knowledge  should  always  be  aimed  at,  and  the  student  will  never 
regret  the  time  and  trouble  he  spends  in  acquiring  it. 

Position  of  the  Head  at  the  commencement  of  Labor. — At  the  com- 
mencement of  labor  the  long  diameter  of  the  head  lies  in  almost  any 
diameter  of  the  pelvic  brim,  except  in  the  antero-posterior,  where 
there  is  not  space  for  it.  In  the  large  majority  of  cases,  however,  it 
enters  the  pelvis  in  one  or  other  of  the  oblique  diameters,  or  in  one 
between  the  oblique  and  transverse ;  but  until  it  has  fairly  passed 
through  the  brirn,  it  more  frequently  lies  directly  in  the  transverse 
diameter  than  has  been  generally  supposed.  Hence  obstetricians  are 
in  the  habit  of  describing  the  head  as  lying  in  four  positions,  accord- 
ing to  the  parts  of  the  pelvis  to  which  the  occiput  points ;  the  first 
and  third  positions  being  those  in  which  the  long  diameter  of  the 
head  occupies  the  right  oblique  diameter  of  the  pelvis,  the  second 
arid  fourth  those  in  which  it  lies  in  the  left  oblique.  Many  sub- 
divisions of  these  positions  have  been  made,  which  only  complicate 
the  subject,  and  render  it  more  difficult  to  understand. 

The  positions,  then,  of  the  foetal  head  after  it  has  entered  the  brim, 
which  it  is  of  importance  to  be  able  to  distinguish  in  practice  are  : — 

First  (or  left  occipito-cotyloid). — The  occiput  points  to  the  left  fora- 
men ovale,  the  sinciput  to  the  right  sacro-iliac  synch ondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of 
the  pelvis. 

Second  (or  right  occipito*cotyloid). — The  occiput  points  to  the  right 
foramen  ovale,  the  forehead  to  the  left  sacro-iliac  synchondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the 
pelvis. 

Third  (or  right  occipito-sacro-iUac). — The  occiput  points  to  the  right 
sacro-iliac  synchondrosis,  the  forehead  to  the  left  foramen  ovale,  and 
the  long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of 
the  pelvis.  This  position  is  the  reverse  of  the  first. 

Fourth  (or  left  occipito-sacro-iliac). — The  occiput  points  to  the  left 
sacro-iliac  synchondrosis,  the  forehead  to  the  right  foramen  ovale, 
and  the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of 
the  pelvis.  This  position  is  the  reverse  of  the  second. 


DELIVERY    IN    HEAD    PRESENTATIONS.  &>» 

Frequency  of  these  Positions. — -The  relative  frequency  of  these 
positions  has  long  been,  and  still  is,  a  matter  of  discussion  among 
obstetricians.  According  to  Naegele,  to  whose  classical  essav  we 

O  «• 

owe  the  greater  part  of  our  knowledge  of  the  subject,  the  head  lies 
in  the  right  oblique  diameter  in  99  per  cent,  of  all  cases.  More  re- 
cent researches  have  thrown  some  doubt  on  the  accuracy  of  these 
figures,  and  many  modern  obstetricians  believe  that  the  second  posi- 
tion, which  Naegele  believed  only  to  be  observed  as  a  transitional 
stage  in  the  natural  progress  of  the  third  position,  is  much  more 
common  than  he  supposed.  This  question  will  be  more  fully  dis- 
cussed when  we  treat  of  the  mechanism  of  occipito-posterior  delivery, 
and,  in  the  meantime,  it  may  serve  to  show  the  discrepancy  which 
exists  in  the  opinions  of  modern  writers,  if  we  append  the  following 
table  of  the  relative  frequency  of  the  various  positions,1  copied  from 
Leishman's  Work: — 


First 
Position. 

Second 
Position. 

Third 
Position. 

Fourth 
Position. 

Not 
Classified 

^Nae^ele 

70. 

29. 

1. 

Naegele,  Jun. 

64.64 

32.88 

2.47 

Simpson  and  Barry 

76.45 

29 

22.68 

.58 

Dubois 

70  83 

2  87 

25  66 

.62 

Murphy      . 

63.23 

16  18 

16.18 

4.42 

Swayne 

86  36 

9  79 

1  04 

2.8 

Here  it  will  be  seen  that  all  obstetricians  are  agreed  as  to  the  im- 
mensely greater  frequency  of  the  first  position — the  only  point  at 
issue  being  the  relative  frequency  of  the  second  and  third. 

Explanation. — Various  explanations  have  been  given  of  the 
greater  frequency  with  which  the  head  lies  in  the  right  oblique 
diameter.  By  some  it  is  referred  to  the  natural  tendency  of  the  back 
of  the  foetus,  as  shown  by  the  experimental  researches  of  Honing 
and  other  writers,  to  be  directed,  in  consequence  of  gravitation,  for- 
wards and  to  the  left  side  of  the  mother  in  the  erect  attitude,  and 
backwards  and  to  her  right  side  in  the  recumbent.  The  explanation 
given  by  Simpson  was  that  the  head  lay  in  the  right  oblique  diame- 
ter in  consequence  of  the  measurement  of  the  left  oblique  being  more 
or  less  lessened  by  the  presence  of  the  rectum.  When  the  rectum  is 
collapsed,  indeed,  the  narrowing  of  the  diameter  is  slight ;  but  it  is 
so  often  distended  by  faecal  matter — sometimes,  when  constipation 
exists,  to  a  very  great  extent — that  it  may  really  have  a  very 
important  influence  in  determining  the  position  of  the  foetal  head. 

In  describing  the  mechanism  of  delivery,  it  will  be  well  for  us  to 
concentrate  our  attention  on  the  first,  or  most  common  position, 
dwelling  subsequently  more  briefly  on  the  differences  between  it  arid 
the  less  common  ones. 

Description  of  the  First  Position. — In  this  position,  when  the  head 


1  Leishman's  System  of  Midwifery,  p.  341. 


258  LABOR. 

commences  to  descend,  the  occiput  lies  in  the  brim  pointing  to  the 
left  ileo-pectineal  eminence,  the  forehead  is  directed  to  the  right 
sacro-iliac  synchondrosis,  and  the  sagittal  suture  runs  obliquely 
across  the  pelvis  in  the  right  oblique  diameter.  The  back  of  the 
child  is  turned  towards  the  left  side  of  the  mother's  abdomen,  the 
right  shoulder  to  her  right  side,  the  left  to  her  left  side  (Fig.  92).  If 

FIG.  92. 


Attitude  of  Child  in  First  Position.     (After  Hodge.) 

a  vaginal  examination  be  now  made  (the  patient  lying  in  the  ordinary 
obstetric  position),  and  the  os  be  sufficiently  open,  the  finger  will 
impinge  upon  the  protuberances  of  the  right  parietal  bone,  which  is 
described  as  the  "presenting  part,"  a  term  which  has  received  various 
definitions,  the  best  of  which  is  probably  that  adopted  by  Tyler 
Smith,  viz.,  "that  portion  of  the  foetal  head  felt  most  prominently 
within  the  circle  of  the  os  uteri,  the  vagina,  and  the  os  tincae,  in  the 
successive  stages  of  labor."  If  the  tip  of  the  examining  finger  be 
passed  slightly  upwards,  it  will  feel  the  sagittal  suture  running 
obliquely  across  the  pelvis  and,  if  this  be  traced  downwards  and  to 
the  left,  it  will  come  upon  the  triangular  posterior  fontanelle,  with 
the  lamboidal  sutures  diverging  from  it.  If  the  finger  could  be 
passed  sufficiently  high  in  the  opposite  direction,  upwards  and  to  the 
right,  it  would  come  upon  the  large  anterior  fontanelle;  but,  at  this 
time,  that  is  too  high  up  to  be  within  reach.  The  chin  is  slightly 
flexed  upon  the  sternum,  this  flexion,  as  we  shall  presently  see, 
being  greatly  increased  as  the  head  begins  to  descend. 

The  head,  at  the  commencement  of  labor,  generally  lies  within  the 
pelvic  brim,  especially  in  primiparae.  In  multipart,  owing  to  the 
relaxation  of  the  abdominal  parietes,  the  uterus  is  apt  to  fall  some- 


DELIVERY    IN    HEAD    PRESENTATIONS. 

what  forwards,  and  the  head  consequently  is  more  entirely  above  the 
brirn,  but  is  pushed  within  it  as  soon  as  labor  actually  commences. 

Naeyeles  Views. — Naegele — and  his  description  has  been  adopted 
by  most  subsequent  writers — describes  the  head,  at  this  period,  as 
lying  obliquely  in  relation  to  the  brim,  the  right  parietal  bone,  on 
which  the  examining  finger  impinges,  being  supposed  by  him  to  be 
much  lower  than  the  left.  The  accuracy  of  this  view  has,  of  late 
years,  been  contested,  and  it  is  now  pretty  generally  admitted  that 
this  obliquity  does  not  exist,  and  that  the  head  enters  the  brim  of 
the  pelvis  with  both  parietal  bones  on  the  same  level,  and  with  its 
biparietal  diameter  parallel  to  the  plane  of  the  inlet  (Fig.  93).  Nae- 

FIG.  93. 


First  Position  :  Movement  of  Flexion. 


gele's  view  was  adopted,  partly  because  the  finger  always  felt  the 
right  parietal  protuberance  lowest,  and  partly  because  it  was  at  that 
point  that  the  "caput  succedaneum,"  or  swelling  observed  on  the  head 
after  delivery,  was  always  formed.  Both  arguments  are,  however, 
fallacious;  for  the  right  parietal  bone  is  the  part  which  would  natu- 
rally be  felt  lowest,  on  account  of  the  oblique  position  of  the  pelvis 
to  the  trunk;  while,  with  regard  to  the  caput  succedaneum,  it  has 
been  conclusively  proved  by  Duncan,  that  it  does  not  form  on  the 
point  most  exposed  to  pressure,  as  Naegele  assumed,  but  on  the  part 
of  the  head  where  there  is  least  pressure,  that  is  the  part  lying  over 
the  axis  of  the  vaginal  canal. 

Division  of  Mechanical  Movements  into  Stages. — In  tracing  the  pro- 
gress of  the  head  from  the  position  just  described,  obstetricians  have 
been  in  the  habit  of  dividing  the  movements  it  undergoes  into  vari- 
ous stages,  which  are  convenient  for  the  purpose  of  facilitating  de- 
scription. It  must  be  borne  in  mind  that  these  are  not  evident  and 
distinct  stages,  which  can  always  be  made  out  in  practice,  but  that 
they  run  insensibly  into  one  another,  and  often  occur  simultaneously, 


260  LABOR. 

or  nearly  so,  in  rapid  labor.  They  may  oe  described  as:  1.  Flexion. 
2.  First  movement  of  descent.  3.  Levelling  or  adjusting  movement. 
4.  Rotation.  5.  /Second  movement  of  descent  and  extension.  6.  Ex- 
ternal rotation. 

1.  Flexion,  the  first  movement  of  the  head,  consists  of  a  rotation 
on  its  bi-parietal  diameter,  by  which  the  chin  of  the  child  becomes 
bent  on  the  sternum,  and  the  occiput  descends  lower  than  the  front 
part  of  the  head.  By  this  there  is  a  clear  gain  of  at  least  a  half  inch, 
for  the  occipito-bregmatic  diameter  (3|  inches)  becomes  subsituted 
for  the  occipito-frontal  (4  inches)  (Fig.  93). 

The  movement  is  most  marked  when  the  pelvis  is  narrow,  and,  in 
some  cases  of  pelvic  deformity,  it  takes  place  to  an  extreme  degree  ; 
while,  in  unusually  large  and  roorny  pelves,  it  occurs  to  a  very  slight 
extent,  or  not  at  all.  The  reason  of  this  flexion  is  twofold.  Solayres 
and  the  majority  of  obstetricians  explain  it  by  saying  that  the  ex- 
pulsive force  is  communicated  to  the  head  through  the  vertebral 
column,  and,  inasmuch  as  the  head  is  articulated  much  nearer  the 
occiput  than  the  sinciput,  the  resistance  being  equal,  the  former  must 
be  pushed  down.  This  is  doubtless  the  correct  explanation  of  the 
flexion  after  the  membranes  are  ruptured ;  but,  before  that  happens, 
the  dvurn  is  practically  a  bag  of  water,  which  is  equally  compressed 
at  all  points  by  the  uterine  contractions,  and  is  pushed  downwards 
through  the  os  en  masse,  the  expulsive  force  not  being  transmitted 
through  the  vertebral  column  at  all.  Under  such  circumstances 
flexion  is  probably  effected  in  the  following  way:  the  head  being  ar- 
ticulated nearer  the  occiput  than  the  forehead,  and  being  equally 
pressed  upon  from  below  by  the  resisting  structures,  the  pressure  is 
more  effectual  on  the  forehead — consequently  that  is  forced  up- 
wards, and  the  occiput  descends.  This  explanation  would  also  hold 
good  after  the  rupture  of  the  membranes,  and  probably  both  causes 
assist  in  effecting  the  movement. 

2  and  3.  Descent  and  Levelling  Movement. — The  movements  of 
descent  and  levelling  may  be  described  together.  As  soon  as  the  head 

FIG.  94. 


First  Position  :  Occiput  in  the  cavity  of  Pelvis.     (After  Hodge.) 

is  liberated  from  the  os  uteri,  it  descends  pretty  rapidly  through  the 
pelvis,  until  the  occiput  reaches  a  point  nearly  opposite  the  lower 
part  of  the  foramen  ovale  (Fig.  94),  and  the  sinciput  is  opposite  the 
second  bone  of  the  sacrum.  A  levelling  movement  now  occurs,  the 


DELIVERY    IX    HEAD    PRESENTATIONS.  261 

anterior  fontanelle  comes  to  be  more  easily  within  reach,  more  on  a 
level  with,  the  posterior,  and  the  chin  is  no  longer  so  much  Hexed  on 
the  sternum.  This  change  is  due  to  the  fact  that  the  anterior  end 
of  the  ovoid  experiences  greater  resistance  than  the  posterior,  and 
as  soon  as  this  resistance  counterbalances  and  exceeds  that  applied 
to  the  latter,  the  sinciput  must  descend.  The  right  side  of  the  head 
also  descends  more  than  the  left  from  a  similar  cause,  so  that  the 
head  becomes,  as  it  were,  slightly  flexed  on  the  right  shoulder.  This 
obliquity  of  the  head  on  its  transverse  diameter  in  the  lower  part  of 
the  pelvis  has  been  denied  by  Kuneke,1  who  maintains  that  the  head 
passes  through  the  entire  pelvis  in  the  same  position  as  it  enters  the 
brim,  that  is.  with  both  parietal  bones  on  a  level,  so  that  the  point 
of  intersection  of  the  transverse  and  antero-posterior  diameters  of 
the  pelvis  would  correspond  with  the  sagittal  suture.  There  is, 
however,  good  reason  to  believe  that,  in  the  lower  half  of  the  pelvic 
cavity,  the  head  is  not  truly  synclitic,  as  Kuneke  describes,  but 
that  the  right  parietal  bone  is  on  a  somewhat  lower  level  than  the 
left, 

4.  Rotation. — The  movement  of  rotation  is  very  important.  By  it 
the  long  diameter  of  the  head  is  changed  from  the  oblique  diameter 
of  the  pelvic  cavity  to  the  antero-posterior  diameter  of  the  outlet 
(Fig.  95),  or  to  a  diameter  nearly  corresponding  to  it,  so  that  the 


First  Position  :  Occiput  at  outlet  of  Pelvis.     (After  Hodge.) 

long  diameter  of  the  head  is  brought  into  relation  with  the  longest 
diameter  of  the  pelvic  outlet.  This  alteration  almost  always  takes 
place,  and  may  be  readily  observed  by  the  accoucheur  who  carefully 
watches  the  progress  of  labor.  Various  explanations  have  been 
given  of  its  causes.  The  one  most  generally  adopted  is,  that  it  is 
due  to  the  projection  inwards  of  the  ischial  spines,  which  narrow  the 
transverse  diameter  of  the  pelvic  outlet.  As  the  pains  force  the 
occiput  downwards,  its  rotation  backwards  is  prevented  by  the  pro- 
jection of  the  left  ischial  spine,  while  its  rotation  forwards  is  favored 
by  the  smooth  bevelled  surface  of  the  ascending  ram  us  of  the 
ischium.  Similarly  the  ischial  spine  on  the  opposite  side  prevents 
the  rotation  forwards  of  the  forehead,  which  is  guided  backwards  to 
the  cavity  of  the  sacrum  by  the  smooth  surface  of  the  sacro-ischi- 

1  Die  Vier  Factoren  der  Geburt,  Berlin,  1869. 


LABOR. 

atic  ligaments.  These  arrangements,  therefore,  give  a  screwlike 
form  to  the  interior  of  the  pelvis ;  and  as  the  pains  force  the  head 
downwards,  they  are  effectual  in  imparting  to  it  the  rotatory  move- 
ment which  is  of  such  importance  in  adapting  it  to  the  longest 
measurement  of  the  outlet. 

By  most  of  the  German  obstetricians  the  influence  of  the  ischial 
spines,  and  of  the  smooth  pelvic  planes  in  producing  rotation  is  not 
admitted.  They  rather  refer  the  change  of  direction  to  the  in- 
creased resistance  the  head  meets  from  the  posterior  wall  of  the 
pelvis,  and  from  the  perineal  structures.  Whichever  part  of  the 
head  first  meets  this  resistance,  which  is  much  greater  than  that  of 
the  anterior  part  of  the  pelvis,  must  necessarily  be  pressed  forwards ; 
and  as.  in  the  large  majority  of  cases,  the  posterior  fontanelle  de- 
scends first,  it  is  thus  pressed  forwards  until  rotation  is  effected. 
This  view  has  the  advantage  of  accounting  equally  well  for  the  rota- 
tion in  occipito-posterior  as  in  occipito-anterior  positions,  the  former 
of  which,  on  the  more  ordinarily  received  theory,  are  not  quite  satis- 
factorily explicable.  It  does  not  follow  that  the  smooth  surfaces  of 
the  pelvic  planes  are  without  influence  in  favoring  the  rotation.  On 
the  contrary,  they  probably  greatly  facilitate  it ;  but  it  is  more  sim- 
ply and  effectually  explained  by  the  latter  theory  than  by  that 
which  attributes  so  important  an  action  to  the  ischial  spines. 

In  some  rare  cases  the  head  escapes  rotation  and  reaches  the  pe- 
rineum still  lying  in  the  oblique  diameter.  Even  here,  however, 
rotation  is  generally  effected,  often  suddenly,  just  as  the  head  is  about 
to  pass  the  vulva,  and  it  is  very  rarely  expelled *in  the  oblique  posi- 
tion. The  movement  at  this  stage  may  be  explained  by  the  peri- 
neum, which  is  attached  at  its  sides,  and  grooved  in  its  centre  ;  to  the 
hollow  so  formed  the  long  diameter  of  the  head  accommodates  itself, 
and  is  thus  rotated  into  the  antero-posterior  diameter  of  the  outlet. 

5.  Extension. — By  the  process  just  described  the  face  is  turned 
back  into  the  hollow  of  the  sacrum ;  but  the  head  does  not  lie  abso- 
lutely in  the  antero-posterior  diameter  of  the  pelvic  outlet,  but 
rather  in  one  between  it  and  the  oblique.  The  occiput  is  still  forced 
down  by  the  pains,  and,  in  consequence  of  its  altered  position,  is  en- 
abled to  pass  between  the  rami  of  the  pubis,  and  advances  until  its 
further  descent  is  checked  by  the  nape  of  the  neck,  which  is  pressed 
under  arid  against  the  arch  of  the  pubes.  By  this  means  the  occiput 
is  fixed,  and,  the  pains  continuing,  the  uterine  force  no  longer  acts 
on  the  occiput,  but  on  the  anterior  part  of  the  head,  which  is  now 
pushed  down  and  separated  from  the  sternum.  This  constitutes 
extension.  As  the  head  descends,  the  soft  structures  of  the  perineum 
are  stretched,  and  the  coccyx  pushed  back  so  as  to  enlarge  the  out- 
let. The  pains  continue  to  distend  the  perineum  more  and  more, 
the  head  advancing  and  receding  with  each  pain.  As  the  forehead 
descends,  the  sub-occipito-bregmatic,  the  sub-occipito-frontal,  and  the 
sub-occipito-mental  diameters  successively  present;  the  occiput  turns 
more  and  more  upwards  in  front  of  the  pubes  (Fig.  96),  and,  at  last, 
the  face  sweeps  over  the  perineum  and  is  born. 

The  mechanical  cause  of  this  movement  may  be  readily  explained. 


DELIVERY    IN    HEAD    PRESENTATIONS 


263 


As  soon  as  the  occiput  has  passed  under  the  arch  of  the  pubis,  and 
is  no  longer  resisted  by  the  anterior  pelvic  walls,  the  head  is  sub- 
jected to  the  action  of  two  forces:  that  of  the  uterine  pressure  act- 
ing downwards  and  backwards ;  and  that  of  the  resistance  of  the 


First  position  :  Head  delivered.     (After  Hodge.) 

posterior  walls  of  the  pelvis  and  the  soft  parts,  acting  almost  directly 
forwards.  The  necessary  result  is  that  the  head  is  pushed  in  a  direc- 
tion intermediate  between  these  two  opposing  forces — that  is,  down- 
wards and  forwards  in  the  axis  of  the  pelvic  outlet. 

In  addition  to  the  slight  obliquity  which  exists  as  regards  the 
direct  relation  of  the  long  diameter  of  the  head  to  the  antero-poste- 
rior  diameter  of  the  outlet  at  the  moment  of  its  expulsion,  the  head 
also  lies  somewhat  obliquely  in  relation  to  its  own  transverse  diame- 
ter, so  that,  in  the  majority  of  cases,  the  right  parietal  bone  is  ex- 
pelled before  the  left. 

6.  External  Rotation. — Shortly  after  the  head  is  expelled,  as  soon  as 
renewed  uterine  action  commences,  it  may  be  observed  to  make  a 


External  Rotation  of  Head  in  First  Position.     (After  Hodge.) 

distinct  rotatory  movement,  the  occiput  turning  to  the  left  thigh  of 
the  mother,  and  the  face  turning  upward  to  the  right  thigh  (Fig.  97). 
The  reason  of  this  is  evident.  When  the  head  descends  in  the  right 


264  LABOR. 

oblique  diameter  the  shoulders  lie  in  the  opposite  or  left  oblique  diam- 
eter, and  as  the  head  rotates  into  the  antero-posterior  diameter,  they 
are  necessarily  placed  more  nearly  in  the  transverse.  As  soon  as  the 
liea<l  is  expelled  the  shoulders  are  subjected  to  the  same  uterine  force 
and  pelvic  resistance  as  the  head  has  just  been,  and  they  are  acted 
on  in  precisely  the  same  way.  Consequently  they  too  rotate,  but  in 
the  opposite  direction,  into  the  antero-posterior  diameter  of  the  out- 
let, or  nearly  so,  just  as  the  head  did,  and  as  they  do  so,  they  neces- 
sarily carry  the  head  with  them,  and  cause  its  external  rotation. 

The  two  shoulders  are  soon  expelled,  the  left  shoulder  generally 
the  first,  sweeping  over  the  perineum  in  the  same  manner  as  the  face. 
This  is,  however,  not  always  the  case,  and  they  are  often  expelled 
simultaneously,  or  the  right  shoulder  may  come  first.  The  body 
soon  follows,  and  the  second  stage  of  labor  is  completed. 

Second  Position. — In  the  second  position  (right  occipito-cotyloid) 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the 
pelvis.  On  making  a  vaginal  examination,  in  the  ordinary  obstetric 
position,  the  finger,  passing  upwards  and  to  the  right,  feels  the  small 
posterior  fontanelle ;  downwards  and  to  the  left,  it  feels  the  anterior. 
The  sagittal  suture  lies  obliquely  across  the  pelvis  in  the  left  oblique 
diameter.  The  description  of  the  mechanism  of  delivery  is  precisely 
the  same  as  in  the  first  position,  substituting  the  word  left  for  right. 
Thus  the  finger  impinges  on  the  left  parietal  bone,  the  occiput  turns 
from  right  to  left  during  rotation.  After  the  birth  of  the  head  the 
occiput  turns  to  the  right  thigh  of  the  mother,  the  face  to  the  left 
thigh 

Third,  or  Right  Occipito-sacro-iliac  Position. — In  the  third  position 
the  head  enters  the  pelvic  brim  with  the  occiput  directed  backwards 

FIG.  98. 


Third  Position  of  Occiput,  at  Brim  of  Pelvis. 


to  the  right  sacro-iliac  synchondrosis,  and  the  sinciput  forwards  to 
the  left  ioramen  ovale  (Fig.  98).     The  posterior  fontanelle  is  directed 


DELIVERY     IN    HEAD    PRESENTATIONS.  265 

backwards,  the  anterior  fontanelle  forwards,  while  the  examining 
finger  impinges  on  the  left  parietal  bone.  The  mechanism  of  de- 
livery in  these  cases  is  of  much  interest.  In  the  large  majority  of 
cases,  during  the  progress  of  delivery,  the  occiput  rotates  forwards 
along  the  right  side  of  the  pelvis,  until  it  comes  to  lie  almost  in  the 
antero-posterior  diameter  of  the  outlet,  and  passes  under  the  pubic 
arch,  the  forehead  passing  over  the  perineum.  It  will  be  seen  that 
during  part  of  this  extensive  rotation  the  head  must  lie  in  the  second 
position,  and  the  case  terminates  just  as  if  it  had  been  in  the  second 
position  from  the  commencement  of  labor. 

Manner  in  which  the  Occiput  is  Rotated  Forwards. — How  is  it  that 
this  rotation  is  effected,  ancl  that  the  sinciput,  occupying  the  position 
of  the  occiput  in  the  first  position,  should  not  be  rotated  forwards  to 
the  pubes  as  that  is  ?  This,  no  doubt,  may  be  explained  by  the  fact, 
that  the  uterine  force  transmitted  through  the  vertebral  column 
causes  the  occiput  to  descend  lower  than  the  sinciput,  so  that  in  most 
cases,  in  making  a  vaginal  examination,  the  posterior  fontanelle  can 
be  readily  felt,  while  the  anterior  is  high  up  and  out  of  reach.  The 
head  is,  therefore,  extremely  flexed,  and  so  descends  into  the  pelvic 
cavit}r,  until  the  occiput,  being  now  below  the  right  ischial  spine, 
experiences  the  resistance  of  the  pelvic  floor,  opposite  the  right  sacro- 
ischiatic  ligament,  by  which  it  is  directed  forwards.  The  forehead 
is,  at  this  time,  supposing  flexion  to  be  marked,  too  high  to  be  in- 
fluenced by  the  anterior  pelvic  plane.  Pressure  continuing,  the 
occiput  rotates  forwards,  the  forehead  passes  round  the  left  side  of 
the  pelvis,  and  labor  is  terminated  as  in  the  second  position. 

The  period  of  labor  at  which  rotation  takes  place  varies.  In  the 
majority  of  cases  it  does  not  occur  until  the  head  is  on  the  floor  of 
the  pelvis,  for  it  is  then  that  resistance  is  most  felt;  but  the  greater 
the  resistance,  the  sooner  will  rotation  be  produced.  Hence  it  is 
more  likely  to  occur  early  when  the  head  is  large,  and  the  pelvis 
comparatively  small. 

The  facility  with  which  this  movement  is  effected  obviously  depends 
upon  the  complete  flexion  of  the  chin  on  the  sternum,  by  which  the 
anterior  fontanelle  is  so  elevated  that  its  rotation  backwards  is  not 
resisted  by  the  inward  projection  of  the  left  ischial  spine,  and  the 
occiput  is  correspondingly  depressed.  If,  however,  this  flexion  is 
not  complete,  and  the  anterior  fontanelle  is  so  low  as  to  be  readily 
within  reach  of  the  finger,  considerable  difficulty  is  likely  to  be 
experienced.  In  many  such  cases  rotation  is  still  eventually  effected, 
but  in  others  it  is  not;  and  the  labor  is  then  terminated  with  the 
face  to  the  pubes,  but  at  the  expense  of  considerable  delay  and  diffi- 
culty. According  to  Dr.  Uvedale  West,  of  Alford,  who  devoted 
much  careful  study  to  the  subject,  this  termination  occurs  in  about 
4  per  cent,  of  occipito-posterior  positions.  When  it  is  about  to 
happen  the  anterior  fontanelle  may  be  felt  very  low  down,  and, 
sometimes,  even  the  forehead  and  superciliary  ridges.  The  uterine 
force  pushes  down  the  occiput,  the  sinciput  being  fixed  behind  the 
pubes,  which  it  obviously  cannot  pass  under, -as  does  the  occiput  in 
the  first  position.  The  sinciput,  therefore,  becomes  more  flexed  and 
18 


266  LABOR. 

pushed  upwards,  while  the  resistance  of  the  pelvic  floor  directs  the 
occiput  forwards.  The  perineum  now  becomes  enormously  distended 
by  the  back  part  of  the  head,  and  is  in  great  danger  of  laceration. 
The  occiput  is  eventually,  but  not  without  much  difficulty,  expelled. 
A  process  of  extension  now  occurs,  the  nape  of  the  neck  being  fixed, 
as  it  were,  against  the  centre  of  the  perineum,  the  expelling  force 
now  acting  on  the  forehead,  and  producing  rotation  of  the  head  on 
its  transverse  axis.  The  forehead  and  face  are  thus  protruded,  and 
the  body  follows  without  difficulty. 

It  is  said  that,  in  a  few  exceptional  cases,  where  the  anterior  fonta- 
nelle  is  much  depressed,  the  labor  may  terminate  by  the  conversion 
of  the  presentation  into  one  of  the  face,  the  head  rotating  on  its 
transverse  axis,  the  forehead  passing  to  the  posterior  part  of  the 
pelvis,  and  the  chin  emerging  under  the  perineum.  It  is  obvious, 
however,  that  this  change  can  only  occur  when  the  head  is  unusually 
small,  and  it  must  of  necessity  be  extremely  rare. 

Relative  frequency  of  Second  and  Third  Positions. — Reference  has 
already  been  made  to  Naegele's  views  as  to  the  rarity  of  the  second 
position,  and  to  his  opinion  that  cases  in  which  the  occiput  was  found 
to  point  to  the  right  foramen  ovale  were  only  transitional  stages  in 
the  rotation  of  occipito-posterior  positions.  Such  an  assumption, 
however,  is  unwarrantable,  unless  the  case  has  been  watched  from 
the  very  commencement  of  labor.  Many  perfectly  qualified  ob- 
servers have  arrived  at  the  conclusion  that  second  positions  are  far 
more  common  than  Naegele  supposed;  and  in  the  table  already 
quoted  it  will  be  seen  that  while  Murphy  estimates  the  second  and 
third  as  being  equally  frequent,  Swayne  believes  the  second  to  be 
much  more  common  than  the  third.  It  is  probable  that  the  weight 
of  Naegele's  authority  has  induced  many  observers  to  classify  second 
positions  as  third  positions  in  which  partial  rotation  has  already  been 
accomplished.  My  own  experience  would  certainly  lead  me  to  think 
that  second  positions  are  very  far  from  uncommon.  The  question, 
however,  must  be  considered  to  be  in  abeyance,  until  further  ob- 
servations by  competent  authorities  enable  us  to  decide  it  conclu- 
sively. 

Fourth  or  Left  Occipito-sacro-ischiatic. — The  fourth  position  is  just 
as  much  the  reverse  of  the  second  as  the  third  is  of  the  first.  The 
occiput  points  to  the  left  (Fig.  99)  sacro-iliac  synchondrosis,  and  the 
finger  impinges  on  the  right  parietal  bone.  The  mechanism  is  pre- 
cisely the  same  as  in  the  third  position,  the  rotation  taking  place 
from  left  to  right. 

Formation  of  the  Caput  Succedaneum. — The  formation  of  the  caput 
succedaneum  lias  been  already  alluded  to.  This  term  is  applied  to 
the  oedematous  swelling  which  forms  on  the  head,  and  is  produced 
by  eft'usion  from  the  obstruction  of  the  venous  circulation  caused  by 
the  pressure  to  which  the  head  is  subjected.  It  follows  that  the  size 
of  the  swelling  is  in  direct  proportion  to  the  length  of  the  labor.  In 
rapid  deliveries,  in  which  the  head  is  forced  through  the  pelvis 
quickly,  it  is  scarcely,  if  at  all,  developed;  while,  after  protracted 
labors,  it  is  large  and  distinct,  and  may  obscure  the  diagnosis  of  the 


DELIVERY    IX    HEAD    PRESENTATIONS.  267 

position,  by  preventing  the  sutures  and  fontanelles  being  felt.     Its 
situation  varies  according  to  the  position  of  the  head:  thus,  in  the 

FIG.  99. 


Fourth  Position  of  Occiput  at  Pelvic  Brim. 

first  and  fourth  positions  it  forms  on  the  right  parietal  bone,  in  the 
second  and  third  on  the  left;  and  we  may,  therefore,  verify,  by 
inspection  of  its  site,  the  accuracy  of  our  diagnosis. 

An  ordinary  mistake  which  has  been  made  by  obstetricians  is  to 
regard  the  caput  succedaneum  as  formed  at  the  point  where  the 
head  has  been  most  subjected  to  pressure ;  while,  in  fact,  it  forms  on 
that  part  which  is  most  unsupported  by  the  maternal  structures,  and 
where  the  swelling  may  consequently  most  readily  occur.  There- 
fore, in  the  early  stages  of  the  labor,  it  always  forms  on  the  part  of 
the  head  which  lies  in  the  circle  of  the  os  uteri ;  while,  in  subsequent 
stages,  it  forms  on  that  which  lies  in  the  axis  of  the  vaginal  canal, 
and  eventually  is  most  prominent  on  the  part  that  is  first  expelled 
from  the  vulva. 

Alteration  in  the  Shape  of  the  Head  from  Moulding. — A  few  words 
may  be  said  as  to  the  alteration  in  the  form  of  the  foetal  head  which 
occurs  in  tedious  labors,  and  results  from  the  moulding  which  it  has 
undergone  in  its  passage  through  the  pelvis.  The  smaller  the  pelvis, 
and  the  greater  the  pressure  applied  to  the  head  during  delivery,  the 
more  marked  this  is.  The  result  is,  that  in  vertex  presentations  the 
occipito-mental  and  occipito-frontal  diameters  are  elongated  to  the 
extent  of  an  inch,  or  even  more,  while  the  transverse  diameters  are 
lessened,  from  compression  of  the  parietal  bones.  This  moulding  is 
of  unquestionable  value  in  facilitating  the  birth  of  the  child.  The 
amount  of  apparent  deformity  is  very  considerable,  and  may  even 
give  rise  to  some  anxiety.  It  is  well  to  remember,  therefore,  that  it 
is  always  transient,  and  that  in  a  few  hours,  or  days  at  most,  the 
elasticity  of  the  soft  cranial  bones  causes  them  to  resume  their  natural 
form.  The  caput  succedaneum  also  disappears  rapidly,  therefore  no 
amount  of  deformity  from  either  of  these  causes  need  give  rise  to 
anxiety,  or  call  for  any  treatment. 


268  LABOR. 


CHAPTER  III. 

MANAGEMENT  OF  NATURAL  LABOR. 

ALTHOUGH  labor  is  a  strictly  physiological  function,  and  in  a  large 
majority  of  cases,  might,  no  doubt,  be  safely  accomplished  without 
assistance  from  the  accoucheur,  still  medical  aid,  properly  given,  is 
always  of  value  in  facilitating  the  process,  and  is  often  absolutely 
essential  for  the  safety  of  the  mother  and  child. 

Preparatory  Treatment, — The  management  of  the  pregnant  woman 
before  delivery  is  a  point  which  should  always  receive  the  attention 
of  the  medical  attendant,  since  it  is  of  consequence  that  the  labor 
should  come  on  when  she  is  in  as  good  a  state  of  health  as  possible. 
For  this  purpose  ordinary  hygienic  precautions  should  never  be 
neglected  in  the  latter  months  of  gestation.  The  patient  should  take 
regular  and  gentle  exercise,  short  of  fatigue,  and,  if  the  weather 
permit,  should  spend  as  much  of  her  time  as  possible  in  the  open  air. 
Hot  rooms,  late  hours,  and  excitement  of  all  kinds  should  be  strictly 
avoided.  The  diet  should  be  simple,  nutritious,  and  unstimulating. 
The  state  of  the  bowels  should  be  particularly  attended  to.  During 
the  few  days  preoeding  labor  the  descent  of  the  uterus  often  causes 
pressure  on  the  rectum,  and  prevents  its  evacuation.  Hence  it  is 
customary  to  prescribe  occasional  gentle  aperients,  such  as  small 
doses  of  castor-oil,  for  a  few  days  before  the  expected  period  of  de- 
livery. Some  caution,  however,  is  necessary,  as  it  is  certainly  not 
very  uncommon  for  labor  to  be  determined  rather  sooner  than  was 
anticipated,  in  consequence  of  the  irritation  of  too  large  a  purgative 
dose.  The  state  of  the  bowels  should  always  be  inquired  into  at  the 
commencement  of  labor,  and,  if  there  be  any  reason  to  suspect  that 
they  are  loaded,  a  copious  enema  should  be  administered.  This  is 
always  a  proper  precaution  to  take,  for  a  loaded  rectum  is  a  common 
cause  of  irregular  and  ineffective  uterine  action ;  and  even  when  it 
does  not  produce  this  result,  the  escape  of  the  faeces,  in  consequence 
of  pressure  on  the  bowel  during  the  propulsive  stage,  is  always  dis- 
agreeable both  to  the  patient  and  practitioner. 

Dress  of  Patient  during  Pregnancy. — The  dress  of  the  patient  dur- 
ing pregnancy  may  be  here  adverted  to ;  for  much  discomfort  may 
arise,  and  the  satisfactory  progress  of  labor  may  even  be  interfered 
with,  from  errors  in  this  respect. 

After  the  uterus  has  risen  out  of  the  pelvis  the  ordinary  corset, 
which  most  women  wear,  is  apt  to  produce  very  injurious  pressure ; 
still  more  so  when  attempts  are  made  to  conceal  the  increased  size 
by  tight  lacing.  After  the  fourth  or  fifth  month,  therefore,  the 
comfort  of  the  patient  is  much  increased  by  wearing  a  specially  con- 
structed pair  of  stays,  with  elastic  let  into  the  sides  and  front,  so  that 


MANAGEMENT  OF  NATURAL  LABOR.  269 

they  accommodate  themselves  to  the  gradual  increase  of  the  figure. 
Such  are  made  by  all  stay-makers,  and  should  be  worn  whenever 
the  circumstances  of  the  patient  permit.  Failing  this,  it  is  better  to 
avoid  the  use  of  the  corset  altogether,  and  to  have  as  little  pressure 
on  the  uterus  as  possible ;  although  many  women  cannot  do  without 
the  support  to  which  they  are  accustomed.  To  multipart,  especially 
if  there  be  much  laxity  of  the  abdominal  parietes,  a  well-fitting  elas- 
tic abdominal  belt  is  often  a  great  comfort.  This  is  constructed  so 
that  it  can  be  tightened  when  the  patient  is  walking  and  in  the  erect 
position,  when  such  support  is  most  required,  and  readily  loosened 
when  desired. 

Necessity  of  Attending  to  the  First  Summons. — It  is  hardly  neces- 
sary to  insist  on  the  necessity  of  the  practitioner  attending  imme- 
diately to  the  first  summons  to  the  patient.  It  is  true  that  he  may 
very  often  be  sent  for  long  before  he  is  actually  required.  But  on 
the  other  hand,  it  is  quite  impossible  to  foresee  what  may  be  the 
state  of  any  individual  case.  By  prompt  attention  he  may  be  able 
to  rectify  a  malposition,  or  prevent  some  impending  catastrophe,  and 
thus  save  his  patient  from  consequences  of  the  utmost  gravity. 

Articles  to  be  taken  by  the  Accoucheur. — The  practitioner  should 
always  be  provided  with  the  articles  which  he  may  require.  The 
ordinary  obstetric  cases,  containing  one  or  two  bottles  and  a  catheter, 
such  as  are  sold  by  most  instrument-makers,  are  cumbrous  and  use- 
less; while  "obstetric  bags  ".are  expensive  luxuries  not  within  the 
reach  of  all.  Every  one  can  manufacture  an  excellent  obstetric  bag 
for  himself,  at  a  small  expense,  by  having  compartments  for  holding 
bottles  stitched  on  to  the  sides  of  an  ordinary  leather  bag,  such  as  is 
sold  for  a  few  shillings  at  any  portmanteau-maker's.  It  is  a  great 
comfort  to  have  at  hand  all  that  may  be  required,  and  the  bag  should 
contain  chloroform,  chloral,  laudanum,  the  liquor  ferri  perchloridi  oi 
the  Pharmacopoeia,  the  liquid  extract  of  ergot,  and  a  hypodermic 
syringe,  with  a  bottle  containing  a  solution  of  ergotine  for  subcuta- 
neous injection.  If  it  also  contain  a  Higginson's  syringe,  a  small 
elastic  catheter,  a  good  pair  of  forceps,  and  one  or  two  suture  needles, 
with  some  silver  wire  or  carbolized  catgut,  the  practitioner  is  pro- 
vided against  any  ordinary  contingency.  Other  articles  that  may 
be  required,  such  as  thread,  scissors,  and  the  like,  are  generally  pro- 
vided by  the  nurse  or  patient. 

Duties  on  first  Visiting  the  Patient. — On  arriving  at  the  house  the 
practitioner  should  have  his  visit  announced  to  the  patient,  and  he 
will  very  often  find  that  the  first  effect  of  his  presence  is  to  arrest 
the  pains  that  have  been  hitherto  progressing  rapidly ;  thereby  af- 
fording a  very  conclusive  proof  of  the  influence  of  mental  impres- 
sions on  the  progress  of  labor.  If  the  pains  be  not  already  propulsive, 
it  is  well  that  he  should  occupy  himself  at  first  in  general  inquiries 
from  the  attendants  as  to  the  progress  of  the  labor,  and  in  seeing 
that  all  the  necessary  arrangements  are  satisfactorily  carried  out,  so 
as  to  allow  the  patient  time  to  get  accustomed  to  his  presence.  If 
he  have  any  choice  in  the  matter,  he  should  endeavor  to  secure  a 
large,  airy,  and  well-ventilated  apartment  for  the  lying-in  room,  as 


270  LABOR. 

far  removed  as  possible  from  without.  He  may  also  see  to  the  bed, 
which  should  be  without  curtains,  and  prepared  for  the  labor  by 
having  a  water-proof  sheeting  laid  under  a  folded  blanket  or  sheet, 
on  which  the  patient  lies.  These  receive  the  discharges  during  la- 
bor, and  can  be  pulled  from  under  the  patient  after  delivery,  so  as 
to  leave  the  dry  clothes  beneath.  Among  the  lower  classes,  the 
lying-in  chamber  is  considered  a  legitimate  meeting-place  for  nu- 
merous female  friends  to  gossip,  whose  conversation  is  often  distress- 
ing, and  is  certainly  injurious,  to  a  woman  in  the  excitable  condition 
associated  with  labor.  The  medical  attendant  should,  therefore,  insist 
on  as  much  quiet  as  possible,  and  should  allow  no  one  in  the  room 
except  the  nurse  and  some  one  friend  whose  presence  the  patient 
may  desire.  The  husband's  presence  must  be  left  to  the  wishes  of 
the  patient.  Some  women  like  their  husbands  to  be  with  them,  while 
others  prefer  to  be  without  them,  and  the  medical  attendant  is  bound 
to  act  in  accordance  with  the  patient's  desire. 

Vaginal  Examination. — If  pains  be  actually  present  a  vaginal  ex- 
amination is  essential,  and  should  not  be  delayed.  It  enables  us  to 
ascertain  whether  the  labor  has  commenced  or  not,  and  whether  the 
presentation  is  natural  or  otherwise.  The  pains,  although  apparently 
severe,  may  be  altogether  spurious,  and  labor  may  not  have  actually 
commenced.  It  is  of  much  importance,  both  for  our  own  credit  and 
comfort,  that  we  should  be  able  to  diagnose  the  true  character  of  the 
pains;  for  if  they  be  so-called  "false"  pains,  we  might  wait  hours 
in  fruitless  expectation  of  progress,  while  delivery  is  still  far  off'. 
The  necessity  of  ascertaining,  therefore,  the  actual  state  of  affairs  need 
not  further  be  insisted  on. 

Character  of  False  Pains. — False  pains  are  chiefly  characterized  by 
their  irregularity,  sometimes  coming  on  at  short  intervals,  sometimes 
with  many  hours  between  them  ;  they  also  vary  much  in  intensity, 
some  being  very  sharp  and  painful,  while  others  are  slight  and  tran- 
sient. In  these  respects  they  differ  from  the  true  pains  of  the  first  stage, 
which  are  at  first  slight  and  short,  and  gradually  recur  with  in- 
creased force  and  regularity.  The  situation  of  the  two  kinds  of  pains 
also  varies,  the  false  pains  being  chiefly  situated  in  front,  while  the 
true  pains  are  most  felt  in  the  back,  and  gradually  shoot  round  to- 
wards the  abdomen.  Nothing  short  of  a  vaginal  examination  will 
enable  us  to  clear  up  the  diagnosis  satisfactorily.  If  the  labor  have 
actually  commenced,  the  os  will  be  more  or  less  dilated,  and  its  edges 
thinned ;  while  with  each  pain  the  cervix  will  become  rigid,  and  the 
membranes  tense  and  prominent.  The  false  pains,  on  the  contrary, 
have  no  effect  on  the  cervix,  which  remains  flaccid  and  undilated ; 
or,  if  the  os  be  sufficiently  open  to  admit  the  tip  of  the  finger,  the 
membranes  will  not  become  prominent  during  the  contraction.  Un- 
der such  circumstances  we  may  confidently  assure  the  patient  that 
the  pains  are  false,  and  measures  should  be  taken  to  remove  the  irri- 
tation which  produces  them.  In  the  large  majority  of  cases  the  cause 
of  the  spurious  pains  will  be  found  to  be  some  disordered  state  of 
the  intestinal  tract ;  and  they  will  be  best  remedied  by  a  gentle  ape- 
rient— such  as  castor-oil,  or  the  compound  colocynth  pill  with  hyos- 


MANAGEMENT  OP  NATURAL  LABOR.  271 

cyamus— followed  by,  or  combined  with,  a  sedative,  sucli  as  twenty 
minims  of  laudanum  or  chlorodyne.  Shortly  after  this  has  been 
administered  the  false  pains  will  die  away,  and  not  recur  until  true 
labor  commences. 

Mode  of  conducting  a  Vaginal  Examination. — For  a  vaginal  exami- 
nation the  patient  is  placed  by  the  nurse  on  her  left  side,  close  to  the 
edge  of  the  bed,  with  the  legs  flexed  on  the  abdomen.  The  prac- 
titioner, being  seated  by  the  edge  of  the  bed,  passes  the  index  finger 
of  the  right  hand,  previously  lubricated  with  lard  or  cold  cream,  up 
to  the  vulva,  and  gently  insinuates  it  into  the  orifice  of  the  vagina, 
then  pushes  it  backwards  in  the  axis  of  the  vaginal  outlet,  and 
finally  turns  it  upwards  and  forwards  so  as  to  more  readily  reach  the 
cervix.  This  it  may  not  always  be  easy  to  do,  for  at  the  commence- 
ment of  labor  the  cervix  may  be  so  high  as  to  be  reached  with  dif- 
ficulty, or  it  may  be  directed  backwards  so  as  to  point  towards  the 
cavity  of  the  sacrum.  The  exploration  is  often  much  facilitated  by 
depressing  the  uterus  from  without,  by  the  left  hand  placed  on  the 
abdomen.  Our  object  is  not  only  to  ascertain  the  state  of  the  cervix 
as  to  softness  and  dilatation,  but  also  the  presentation,  the  condition 
of  the  vagina,  and  the  capacity  of  the  pelvis.  The  examination  is 
generally  commenced  during  a  pain,  at  which  time  it  is  less  distress- 
ing to  the  patient ;  but  in  order  to  be  satisfactory,  the  finger  must 
remain  in  the  vagina  until  the  pain  is  over,  the  examination  being 
concluded  in  the  interval  between  this  pain  and  the  next. 

In  head  presentations  the  round  mass  of  the  cranium  is  generally 
at  once  felt  through  the  lower  part  of  the  uterus,  and  then  we  have 
the  satisfaction  of  being  able  to  assure  the  patient  that  all  is  right. 
If  the  os  be  sufficiently  dilated,  we  can  also  feel  through  it  the  occi- 
put covered  by  the  membranes.  It  is  impossible  at  this  time  to 
make  out  the  exact  position  of  the  head  by  means  of  the  sutures  and 
fontanelles,  which  are  too  high  up  to  be  within  reach.  Nor  should 
any  attempt  be  made  to  do  so,  for  fear  of  prematurely  rupturing  the 
membranes.  The  fact  that  the  head  is  presenting  is  all  that  we 
require  to  know  at  this  stage  of  the  labor. 

The  Condition  of  the  Os  as  indicating  the  Progress  of  Lahor. — The 
condition  of  the  os  itself,  as  to  rigidity  and  dilatation,  will  materially 
assist  us  in  forming  an  opinion  as  to  the  progress  and  probable  dura- 
tion of  the  labor ;  but,  although  the  friends  will  certainly  press  for 
an  opinion  on  this  point,  the  cautious  practitioner  will  be  careful  not 
to  commit  himself  to  a  positive  statement,  which  may  so  easily  be 
falsified.  It  will  suffice  to  assure  the  friends  that  everything  is  satis- 
factory, but  that  it  is  impossible  to  say  with  any  certainty  how 
rapidly,  or  the  reverse,  the  case  may  progress. 

If  the  pains  be  not  very  frequent  or  strong,  and  the  os  not  dilated 
to  more  than  the  size  of  a  shilling,  a  considerable  delay  may  be  antici- 
pated, and  the  presence  of  the  medical  attendant  is  useless.  He 
may,  therefore,  safely  leave  the  patient  for  an  hour  or  more,  provided 
he  be  within  easy  reach.  It  is  needless  to  say  that  this  should  never 
be  done  unless  the  exact  presentation  be  made  out.  If  some  part, 
other  than  the  head,  be  presenting,  it  will  probably  be  impossible  to 


272  LABOR. 

make  it  out  until  dilatation  has  progressed  further ;  and  the  prac- 
titioner must  be  incessantly  on  the  watch  until  the  nature  of  the  case 
be  made  out,  so  as  to  be  able  to  seize  the  most  favorable  moment  for 
interference,  should  that  be  necessary. 

Position  of  Patient  during  First  /Stage. — The  position  of  the  patient 
is  a  matter  of  some  moment  in  the  first  stage.  It  is  a  decided  ad- 
vantage that  she  should  not  be  then  in  a  recumbent  position  on  her 
side,  as  is  usual  in  the  second  stage ;  for  it  is  of  importance  that  the 
expulsive  force  should  act  in  such  a  way  as  to  favor  the  descent  ot 
the  head  into  the  pelvis,  i.  e.,  perpendicularly  to- the  plane  of  its  brim, 
and  also  that  the  weight  of  the  child  should  operate  in  the  same  way. 
Therefore,  the  ordinary  custom  of  allowing  the  patient  to  walk 


Examination  during  the  first  stage. 

about,  or  to  recline  in  a  chair,  is  decidedly  advantageous ;  and  it  will 
often  be  observed  that  the  pains  are  more  lingering  and  ineffective  if 
she  lie  in  bed.  If  the  patient  be  a  multipara,  or  if  the  abdomen  be 
somewhat  pendulous,  an  abdominal  bandage,  by  supporting  the 
uterus,  will  greatly  favor  the  progress  of  this  stage.  Keeping  the 
patient  out  of  bed  has  the  further  advantage  of  preventing  her  be- 
ing unduly  anxious  for  the  termination  of  the  labor ;  and  a  little 
cheerful  conversation  will  keep  up  her  spirits,  and  obviate  the  mental 
depression  which  is  so  common.  Good  beef-tea  may  be  freely  ad- 
ministered, with  a  little  brandy  and  water,  occasionally,  if  the  patient 
be  weak,  and  will  be  useful  in  supporting  her  strength. 

Vaginal  Examinations. — Over-frequent  vaginal  examinations  at 
this  period  should  be  avoided,  for  they  serve  no  useful  purpose,  and 


MANAGEMENT  OF  NATURAL  LABOR.  273 

are  apt  to  irritate  the  cervix.  It  will  be  necessary,  however,  to  as- 
certain the  progress  of  the  dilatation  at  intervals. 

Artificial  Rupture  of  the  Membranes.- — When  once  the  os  is  fully  di- 
lated the  membranes  may  be  artificially  ruptured  if  they  have  not 
broken  spontaneously,  for  they  no  longer  serve  any  useful  purpose, 
and  only  retard  the  advent  of  the  propulsive  stage.  This  can  be 
easily  done  by  pressing  on  them,  when  they  are  rendered  tense  dur- 
ing a  pain,  by  some  pointed  instrument,  such  as  the  end  of  a  hair- 
pin, which  is  always  at  hand.  In  some  cases,  indeed,  it  is  even 
expedient  to  rupture  the  membranes  before  the  os  is  fully  dilated. 
Thus  it  not  infrequently  happens,  when  the  amount  of  liquor  amnii 
is  at  all  excessive,  that  the  os  dilates  to  the  size  of  a  five-shilling- 
piece  or  more ;  but,  although  it  is  perfectly  soft  and  flaccid,  it  opens 
up  no  further  until  the  liquor  amnii  is  evacuated,  when  the  propul- 
sive pains  rapidly  complete  its  dilatation.  Some  experience  and 
judgment  are  required  in  the  detection  of  such  cases,  for  if  we  evacu- 
ated the  liquor  amnii  prematurely  the  pressure  of  the  head  on  the 
cervix  might  produce  irritation,  and  seriously  prolong  the  labor. 
This  manoeuvre  is  most  likely  to  be  useful  when  the  pains  are  strong 
and  the  os  perfectly  flaccid,  but  when  the  membranes  do  not  protrude 
through  the  os  and  effect  further  dilatation. 

It  is  sometimes  not  easy  to  ascertain  whether  the  membranes  are 
ruptured  or  not.  This  is  most  likely  to  be  the  case  when  the  head 
is  low  down,  and  the  amount  of  liquor  amnii  is  so  small  that  the 
pouch  does  not  become  prominent  during  the  pains.  A  little  care, 
however,  will  enable  us,  if  the  membranes  be  ruptured,  to  feel  the 
rugosities  of  the  scalp  covered  with  hair,  and  to  distinguish  it  from 
the  smooth  polished  surface  of  the  membranes. 

Treatment  of  the  Propulsive  Stage. — After  the  evacuation  of  the 
liquor  amnii  there  is  generally  a  lull  in  the  progress  of  the  labor,  the 
pains,  however,  soon  recurring  with  increased  force  and  frequency, 
and  propelling  the  head  through  the  pelvic  cavity.  The  change  in 
the  character  of  the  pains  is  soon  appreciated  by  the  bearing  down 
efforts  by  which  they  are  accompanied,  as  well  as  by  their  increased 
length  and  intensity. 

Position  of  the  Patient  during  the  /Second  Stage. — It  is  now  advisa- 
ble that  the  patient  be  placed  in  bed;  and  in  this  country  it  is  usual 
for  her  to  lie  on  her  left  side,  with  her  nates  parallel  to  the  edge  of 
the  bed,  and  her  body  lying  across  it.  This  is  the  established  ob- 
stetric position  in  England,  and  it  would  be  useless  to  attempt  to  in- 
sist on  any  other,  even  if  it  were  advisable.  Although  the  dorsal 
position  is  preferred  on  the  Continent  and  in  America,1  it  is  difficult 
to  see  wherein  its  advantages  consist.  It  certainly  leads  to  unneces- 
sary exposure  of  the  person,  and  it  is,  on  the  whole,  less  easy  to 
reach  the  patient,  so  placed,  for  the  necessary  manipulations.  More- 
over, the  dorsal  position  increases  the  risk  of  laceration  of  the  peri- 

['  In  the  United  States,  the  dors.nl  position  is  rarely  used,  except  where  forceps  are 
applied,  craniotomy  is  resorted  to,  or  the  uterus  is  much  anteverted.  In  ordinary 
labors,  the  woman  is  placed  on  her  left  side,  as  in  England. — ED.] 


274  LABOR. 

neum,  by  bringing  the  weight  of  the  child's  head  to  bear  more 
directly  upon  it.  Thus  Schroeder  found  that  lacerations  occurred  in 
37.6  per  cent,  of  cases  delivered  on  the  back,  as  against  24,-i  per 
cent,  in  other  positions. 

The  patient  usually  remains  in  bed  during  the  whole  of  this  stage, 
and  it  is  customary  for  the  nurse  to  tie  to  the  foot  of  the  bed  a  jack- 
towel,  which  is  laid  hold  of  and  used  as  a  support  in  making  bearing 
down  efforts.  If  the  pains  be  few  and  far  between,  and  the  patient 
finds  it  more  comfortable  to  get  up  occasionally,  there  is  no  reason 
why  she  should  not  do  so.  On  the  contrary,  as  we  shall  subsequently 
see  in  treating  of  lingering  labor,  the  pains  under  such  circumstances 
are  often  increased  in  the  sitting  posture,  in  consequence  of  the 
weight  of  the  child  producing  increased  pressure  on  the  nerves  of 
the  vagina. 

Detection  of  the  Position  of  the  Head. — At  this  time  vaginal  exami- 
nation, which  should  be  more  frequently  repeated  than  in  the  first 
stage,  enables  us  to  ascertain  precisely  the  position  of  the  head,  by 
means  of  the  sutures  and  fontanelles,  as  well  as  to  watch  its  progress. 

Management  of  the  Anterior  Lip  of  Cervix  when  impacted  between 
the  Head  and  Pelvis. — It  not  infrequently  happens  that  the  head 
descends  into  the  pelvis,  even  to  its  floor,  without  the  os  having 
entirely  disappeared.  The  anterior  lip  especially  is  apt  to  get  caught 
between  the  head  and  pubis,  to  become  swollen  by  the  pressure  to 
which  it  is  subjected,  and  then  to  retard  the  progress  of  the  labor. 
There  can  be  no  reasonable  objection  to  attempting  to  prevent  this 
cause  of  delay  by  pressing  on  the  incarcerated  lip  during  the  inter- 
val of  the  pains',  so  as  to  push  it  above  the  head,  and  maintain  it 
there  during  the  pains,  until  the  head  descends  below  it.  This 
manoeuvre,  if  done  judiciously,  and  without  any  undue  roughness  or 
force,  is  certainly  not  liable  to  be  attended  by  any  of  the  evil  con- 
sequences which  many  obstetricians  have  attributed  to  it;  it  is 
indeed  a  matter  of  common  sense  that  the  injury  to  the  cervix  is 
likely  to  be  less  if  it  be  pushed  gently  out  of  the  way,  than  if  it  be 
left  to  be  tightly  jammed  for  hours  between  the  presenting  part  and 
the  bony  pelvis.  This  mode  of  assistance  is  very  different  from  the 
digital  dilatation  of  a  rigid  cervix,  which  was  formerly  much  prac- 
tised, especially  in  Edinburgh,  in  consequence  of  the  recommendation 
of  Hamilton,  and  which  was  properly  objected  to  by  the  great  ma- 
jority of  obstetricians. 

If  the  pains  be  producing  satisfactory  progress,  no  further  interfe- 
rence is  required.  The  medical  attendant  should,  however,  see  that 
the  bladder  is  evacuated ;  and  if  it  have  not  been  so  for  some  hours, 
it  may  be  necessary  to  draw  off  the  urine  by  the  catheter.  When- 
ever the  labor  is  lengthy,  he  should  occasionally  practise  auscultation, 
so  as  to  satisfy  himself  that  the  foetal  circulation  is  being  satisfactorily 
carried  on. 

Regulation  of  the  Voluntary  Bearing-down  Efforts. — The  regulation 
of  the  bearing-down  efforts  at  this  time  is  of  importance.  It  is  com- 
mon for  the  nurse  to  urge  the  patient  to  help  herself  by  straining, 
and  it  is  certain  that  by  voluntary  exertion  of  this  kind  she  can 


MANAGEMENT  OF  NATURAL  LABOR.  270 

materially  increase  the  action  of  the  accessory  muscles  of  parturition. 
If  the  pains  be  strong,  and  the  labor  promise  to  be  rapid,  such 
voluntary  exertions  are  not  likely  to  be  prejudicial.  On  the  other 
hand,  if  the  case  be  progressing  slowly,  they  only  unnecessarily 
fatigue  the  patient,  and  should  be  discouraged.  When  the  perineum 
is  distended  we  may  even  find  it  advisable  to  urge  the  patient  to 
cease  all  voluntary  effort,  and  to  cry  out,  for  the  express  purpose  of 
lessening  the  tension  to  which  the  perineum  is  subjected.  This  is 
the  stage  in  which  anaesthesia  is  most  serviceable,  but  its  employment 
must  be  separately  discussed. 

Distension  of  the  Perineum. — As  the  head  descends  more  and  more 
the  perineum  becomes  distended,  and  there  is  considerable  difference 
of  opinion  amongst  accoucheurs  as  to  the  management  of  the  case 
at  this  time.  In  most  obstetric  works  the  practitioner  is  advised  to 
endeavor  to  prevent  laceration  by  the  manoeuvre  that  is  described 
as  "supporting  the  perineum."  By  this  is  meant,  laying  the  palm 
of  the  hand  on  the  distended  structures,  and  pressing  firmly  upon 
them  during  the  acme  of  the  pain,  with  the  view  of  mechanically 
preventing  their  tearing.  There  can  be  little  doubt  that  this,  or 
some  modification  of  it,  is  the  practice  now  followed  by  the  large 
majority  of  practitioners.  Of  late  years  the  evil  effects  likely  to 
follow  it  have  been  specially  dwelt  upon  by  Graily  Hewitt,  Leishman, 
Goodell,  and  other  writers,  who  maintain  that  by  pressure  exerted  in 
this  fashion  we  not  only  fail  to  prevent,  but  actually  favor  laceration, 
in  consequence  of  the  pressure  producing  increased  uterine  action, 
just  at  the  time  when  forcible  distension  of  the  perineum  is  likely  to 
be  hurtful.  Therefore  some  hold  that  the  perineum  ought  to  be  left 
entirely  alone,  and  that  the  head  should  be  allowed  gradually  to  dis- 
tend it,  without  any  assistance  on  the  part  of  the  practitioner. 

Much  error  may  be  traced  to  a  misconception  of  what  is  required. 
The  term  "supporting  the  perineum"  conveys  an  unquestionably 
erroneous  idea,  and  it  is  certain  that  no  one  can  prevent  laceration 
by  mechanical  support.  If  the  term  "relaxation  of  the  perineum" 
were  employed,  we  should  have  a  far  more  accurate  idea  of  what 
should  be  aimed  at,  and  if  this  be  borne  in  mind,  I  think  it  cannot 
be  questioned  that  nature  may  be  most  usefully  assisted  at  this 
stage. 

Dr.  GoodeWs  Method. — Dr.  Goodell,  of  Philadelphia,  has  specially 
studied  this  subject,  and  has  recommended  a  method,  the  object  of 
.which  is  to  relax  the  perineum.  His  advice  is,  that  one  or  two 
fingers  of  the  left  hand  should  be  inserted  into  the  rectum,  by  which 
the  perineum  should  be  hooked  up  and  pulled  forward  over  the  head, 
towards  the  pubis,  the  thumb  of  the  same  hand  being  placed  on  the 
advancing  head,  so  as  to  restrain  its  progress  if  needful.  I  have 
adopted  this  plan  frequently,  and  believe  that  it  admirably  answers 
its  purpose,  especially  when  the  perineum  is  greatly  distended,  and 
laceration  is  threatened.  It  must  be  admitted  that  the  insertion  of 
the  fingers  into  the  anal  orifice,  in  the  manner  recommended,  is  re- 
pugnant both  to  the  practitioner  and  patient,  and  the  same  result 
can  be  obtained  in  a  less  unpleasant  way.  I  mention  it,  however,  to 


276  LABOR. 

show  what  it  is  that  the  practitioner  must  aim  at.  If,  when  the  head 
is  distending  the  perineum  greatly,  the  thumb  and  forefinger  of  the 
right  hand  are  placed  along  its  sides,  it  can  be  pushed  gently  forward 
over  the  head  at  the  height  of  the  pain,  while  the  tips  of  the  fingers 
may,  at  the  same  time,  press  upon  the  advancing  vertex,  so  as  to 
retard  its  progress  if  advisable  (Fig.  101).  By  this  means  the  sud- 

FIG. 101. 


Mode  of  effecting  relaxation  of  the  Perineum. 

den  and  forcible  stretching  of  the  perinea!  structures  is  prevented, 
and  the  chance  of  laceration  reduced  to  a  minimum,  while  nature's 
mode  of  relaxing  the  tissues,  by  dilatation  of  the  anal  orifice,  is 
favored.  This  is  very  different  from  the  mechanical  support  that  is 
usually  recommended,  and  the  less  pressure  that  is  applied  directly 
to  the  perineum  the  better.  Nor  is  it  either  needful  or  advisable  to 
sit  by  the  patient  with  the  hand  applied  to  the  perineum  for  hours, 
as  is  so  often  practised.  Time  should  be  given  for  the  gradual  dis- 
tension of  the  tissues  by  the  alternate  advance  and  recession  of  the 
head,  and  we  need  only  intervene  to  assist  relaxation  when  the 
stretching  has  reached  its  height,  and  the  head  is  about  to  be  ex- 
pelled. A  napkin  may  be  interposed  between  the  hand  and  the  skin, 
for  the  purpose  of  cleanliness.  Should  the  perineum  be  excessively 
tough  and  resistant,  assiduous  fomentation  with  a  hot  sponge  may 
be  resorted  to,  and  will  be  of  some  service  in  promoting  relaxation. 
Incision  of  the  Perineum. — When  the  tension  is  so  great  that  lace- 
ration seems  inevitable,  it  is  generally  recommended  that  a  slight 
incision  should  be  made  on  each  side  of  the  central  raphe*,  with  the 
view  of  preventing  spontaneous  laceration.  This  may  no  doubt  be 
done  with  perfect  safety,  but  I  question  if  it  is  likely  to  be  of  use. 
The  idea  is  that  an  incised  wound  is  likely  to  heal  more  readily  than 
a  lacerated  one.  When,  however,  a  distended  perineum  ruptures,  its 


MANAGEMENT  OF  NATURAL  LABOR. 


077 


structures  are  so  thinned  that  the  tear  is  always  linear;  and,  as  a 
matter  of  fact,  the  edges  of  the  tear  are  always  as  clean,  and  as 
closely  in  apposition,  as  if  the  cut  bad  been  made  with  a  knife. 
Moreover,  the  laceration  invariably  heals  perfectly,  if  only  the  edges 
be  brought  into  contact  at  once  with  one  or  two  metallic  sutures.  I 
believe,  therefore,  that  Goodell  is  right  in  stating  that  incision  of  the 
perineum  is  rarely,  if  ever,  necessary,  unless  it  is  hardened  by  pre- 
vious cicatrization.  In  almost  all  first  labors,  the  fourchette  is  torn, 
but  requires  no  treatment  of  any  kind.  In  some  cases,  do  what  we 
will,  more  or  less  laceration  occurs,  and  the  perineum  should  always 
be  examined  after  the  expulsion  of  the  child,  to  see  if  any  tear  has 
taken  place. 

Treatment  of  Lacerations. — If  it  has  given  way  to  any  extent,  I 
believe  that  it  is  good  practice  to  insert  one  or  two  interrrupted  su- 
tures of  silver  wire  or  carbolized  gut  at  once.  Immediately  after 
delivery  the  sensibility  of  the  tissues  is  deadened  by  the  distension 
to  which  they  have  been  subjected,  and  the  sutures  can  be  inserted 
with  little  or  no  pain.  It  is  quite  true  that  lacerations  of  an  inch  or 
less  will  generally  heal  perfectly  well  of  themselves ;  but  this  is  not 
invariably  the  case,  while  healing  almost  certainly  follows  if  the 
edges  be  brought  together  at  once.  In  the  severer  forms  of  lacera- 
tion, extending  back  to,  or  even  through  the  sphincter,  the  precaution 
is  all  the  more  necessary,  and  a  subsequent  operation  of  gravity  may 
in  this  way  be  avoided.  The  sutures  can  be  removed  without  diffi- 
culty in  a  week  or  so,  when  complete  adhesion  has  taken  place. 

Expulsion  of  the  Child. — The  head,  when  expelled,  should  be  re- 
ceived in  the  palm  of  the  right  hand,  while  the  left  hand  is  placed 
upon  the  abdomen  to  follow  down  the  uterus  as  it  contracts  and 
expels  the  body.  There  is  generally  some  little  delay  after  the  ex- 
pulsion of  the  head,  and  we  should  now  see  if  the  cord  surround  the 
neck,  and,  if  it  does  so,  it  should  be  drawn  over  the  head.  The  ex- 
pulsion of  the  body  should  be  left  entirely  to  the  uterine  contrac- 
tions. If  there  be  undue  delay  we  may  endeavor  to  excite  uterine 
action  by  friction  on  the  fundus,  and  it  will  rarely  happen  that 
sufficient  contraction  does  not  now  come  on.  If  we  display  undue 
haste  in  withdrawing  the  body,  we  run  the  risk  of  emptying  the 
uterus  while  its  tissues  are  relaxed,  and  so  favor  hemorrhage.  If, 
however,  there  seem  serious  danger  of  the  child  being  asphyxiated, 
its  expulsion  may  be  favored  by  gently  passing  the  forefinger  of  each 
hand  within  the  axillas,  and  using  traction ;  but  it  is  only  very 
exceptionally  that  such  interference  is  required. 

Promotion  of  Uterine  Contraction  after  the  Birth  of  the  Child. — As 
the  uterus  contracts,  it  should  be  carefully  followed  down  through 
the  abdominal  parietes  by  the  left  hand,  which  should  grasp  it  as  the 
body  is  expelled,  with  the  view  of  seeing  that  it  is  efficiently  con- 
tracted. This  is  a  point  of  vital  importance  in  preventing  hemorrhage, 
which  will  presently  be  more  especially  considered. 

Ligature  of  the  Cord. — As  soon  as  the  child  cries  we  may  proceed 
to  tie  and  separate  the  cord.  For  this  purpose  the  nurse  usually 
provides  ligatures  composed  of  several  strands  of  whitey-brown 


278  LABOR. 

thread ;  but  tape,  or  any  other  suitable  material,  may  be  employed. 
It  is  important,  especially  if  the  cord  be  very  thick  and  gelatinous, 
to  see  that  it  is  thoroughly  compressed,  so  that  the  vessels  are  ob- 
literated, otherwise  secondary  hemorrhage  might  occur.  The  cord 
is  tied  about  an  inch  and  a  half  from  the  child,  and  it  is  usual,  though 
of  course  not  essential,  to  place  a  second  ligature  about  two  inches 
nearer  the  placental  extremity  of  the  cord.  The  latter  is,  perhaps, 
of  some  use  by  retaining  the  blood,  and  thus  increasing  the  size  of, 
the  placenta,  and  favoring  its  more  ready  expulsion  by  uterine  con- 
traction. The  cord  is  then  divided  with  scissors  between  the  liga- 
tures, the  child  wrapped  up  in  flannel,  and  given  to  the  nurse,  or  a 
bystander,  to  hold,  while  the  attention  of  the  practitioner  is  concen- 
trated on  the  mother,  with  a  view  to  the  proper  management  of  the 
third  stage  of  labor. 

Importance  of  Proper  Management  of  Third  Stage. — There  is  un- 
questionably no  period  of  labor  where  skilled  management  is  more 
important,  and  none  in  which  mistakes  are  more  frequently  made. 
By  proper  care  at  this  time  the  risk  of  post-partum  hemorrhage  is 
reduced  to  a  minimum,  the  efficient  contraction  of  the  uterus  is 
secured,  the  amount  and  intensity  of  after-pains  are  lessened,  and  the 
safety  and  comfort  of  the  patient  greatly  promoted.  Moreover,  the 
general  practice,  as  to  the  management  of  this  stage,  is  opposed  to 
the  natural  mechanism  of  placental  expulsion,  and  is  far  from  being 
well  adapted  to  secure  the  important  objects  which  we  ought  to  have 
in  view.  Let  us  see  \vhat  is  the  practice  usually  recommended  and 
followed,  and  then  we  shall  be  in  a  position  to  understand  in  what 
respects  it  is  erroneous.  For  this  purpose  I  cannot  do  better  than 
copy  the  directions  contained  in  one  of  our  most  deservedly  popular 
obstetric  text-books,  which  undoubtedly  expresses  the  usual  practice 
in  the  management  of  this  stage.  "  When  the  binder  is  applied,  the 
patient  may  be  allowed  to  rest  a  while,  if  there  is  no  flooding ;  after 
which,  when  the  uterus  contracts,  gentle  traction  may  be  made  by  the 
funis,  to  ascertain  if  the  placenta  be  detached.  If  so,  and  especially 
if  it  be  in  the  vagina,  it  may  be  removed  by  continuing  the  traction 
steadily  in  the  axis  of  the  upper  outlet  at  first,  at  the  same  time 
making  pressure  on  the  uterus."1 

Objections  to  Ordinary  Practice. — This  may  fairly  be  taken  as  a 
sufficiently  accurate  description  of  the  practice  usually  followed.2 
The  objections  I  have  to  make  are :  (1)  That  it  inculcates  the 
common  error  of  relying  on  the  binder  as  a  means  of  promoting 
uterine  contraction,  advising  its  application  before  the  expulsion  of 
the  placenta  ;  while  I  hold  that  the  binder  should  never  be  applied 
until  after  the  placenta  is  expelled,  and  not  even  then,  unless  the 
uterus  is  perfectly  and  permanently  contracted.  (2)  That  it  teaches 
that  traction  on  the  cord  should  be  used  as  a  means  of  withdraw- 
ing the  placenta ;  whereas  the  uterus  itself  should  be  made  to  expel 
the  after-birth,  and,  in  nineteen  cases  out  of  twenty,  the  finger  need 

1  Churchill's  Theory  and  Practice  of  Midwifery,  p.  162. 

2  This  practice  is  further  illustrated  by  the  annexed  diagram,  contained  in  most 


MANAGEMENT  OF  NATURAL  LABOR.  279 

never  be  introduced  into  the  vagina  after  the  birth  of  the  child,  nor 
the  cord  touched.  This  mav  seem  an  exaggerated  statement  to  those 
who  have  accustomed  themselves  to  the  usual  method  of  dealing  with 
the  placenta ;  but  I  feel  confident  that  all  who  have  learnt  the  method 
of  expression  of  the  placenta  would  testify  to  its  accuracy. 

Expression  of  the  Placenta.- — -The  cardinal  point  to  bear  in  mind  is, 
that  the  placenta  should  be  expelled  from  the  uterus  by  a  vis  a  tcr/jo, 
not  drawn  out  by  a  vis  a.  f route.  That  uterine  pressure  after  the 
birth  of  the  child  has  been  recommended  by  many  English  writers 
is  certain,  and  the  Dublin  school  especially  have  dwelt  on  its  import- 
ance as  a  preventive  of  post-parturn  hemorrhage ;  but  the  distinct 
enunciation  of  the  doctrine  that  the  placenta  should  be  pressed,  and 
not  drawn,  out  of  the  uterus,  we  owe  to  Crede  and  other  German, 
writers ;  and  it  is  only  of  late  years  that  this  practice  has  become  at 
all  common.  Those  who  have  not  seen  placental  expression  prac- 
tised, find  it  difficult  to  understand  that,  in  the  large  majority  of 
cases,  the  uterus  may  be  made  to  expel  the  placenta  out  of  the  va- 
gina ;  but  such  is  unquestionably  the  fact.  A  little  practice  is  no 
doubt  necessary  to  effect  this  satisfactorily ;  but  when  once  the 
knack  has  been  learnt,  there  is  little  difficulty  likely  to  be  ex- 
perienced, 

Importance  of  not  Removing  the  Placenta  Hurriedly. — Before  de- 
scribing the  method  of  placental  expression,  a  word  of  caution  may 
be  said  against  undue  haste  in  attempting  expression  of  the  placenta, 
a  mistake  that  is  often  made,  and  which,  I  believe,  tends  to  increase 

obstetric  works,  which  represents  the  accoucheur  as  withdrawing  the  placenta  by  trac- 
tion, and  which  I  insert  as  an  illustration  of  what  ought  not  to  be  done  (Fig,  102). 

FIG.  102. 


Usual  Method  of  Removing  the  Placenta  by  Traction  on  the  Cord. 


280 


LABOR. 


the  risk  of  post-part um  hemorrhage.  So  long  as  we  satisfy  ourselves 
that  the  uterus  is  fairly  contracted,  so  as  to  avoid  the  possibility  of 
its  distension  with  blood,  a  certain  delay  after  the  birth  of  the  child 
is  useful,  from  its  giving  time  for  coagula  to  form  within  the  uterine 
sinuses,  by  which  their  open  mouths  are  closed  up.  The  importance 
of  this  point  has  been  specially  dwelt  upon  by  M'Clintock,  who  lavs 
down  the  rule  that  15  or  20  minutes  should  be  allowed  to  elapse, 
after  the  birth  of  the  child,  before  any  attempt  to  remove  the  after- 
birth is  made.  This  is  a  good  and  safe  practical  rule,  as  it  gives 
ample  time  for  the  complete  detachment  of  the  placenta,  and  the  co- 
agulation of  the  blood  in  the  uterine  sinuses. 

Mode  of  Effecting  Expression  of  the  Placenta. — During  this  inter- 
val the  practitioner  or  nurse  should  sit  by  the  bedside,  with  the  hand 
on  the  uterus  to  secure  contraction  and  prevent  distension :  but  not 
kneading  or  forcibly  compressing  it.  When  we  judge  that  a  suffi- 
cient time  has  elapsed,  we  may  proceed  to  effect  expulsion.  For 
this  purpose  the  fundus  should  be  grasped  in  the  hollow  of  the  left 
hand,  the  ulnar  edge  of  the  hand  being  well  pressed  down  behind 
the  fundus,  and  when  the  uterus  is  felt  to  harden,  strong  and  firm  pres- 
sure should  be  made  downwards  and  backwards  in  the  axis  of  the 
pelvic  brim.  If  this  manoeuvre  be  properly  carried  out,  and  suffi- 
ciently firm  pressure  made,  in  almost  every  case  the  uterus  may  be 
maoje  to  expel  the  placenta  into  the  bed,  along  with  any  coagula  that 
may  be  in  its  cavity  (Fig.  103).  The  uterine  surface  of  the  pla- 

FIG. 103. 


Illustrating  Expression  of  the  Placenta. 

ceuta  is  generally  expelled  first,  as  is  represented  in  the  diagram,  the 
cord  being  within  the  membranes ;  whereas  the  foetal  surface,  and 
root  of  the  cord,  are  the  parts  which  appear  first  when  the  placenta 
is  removed  by  traction  (Fig.  102).  If  we  do  not  succeed  at  the  first 
effort,  which  is  rarely  the  case  if  extrusion  be  not  attempted  too 
soon  after  the  birth  of  the  child,  we  may  wait  until  another  contrac- 


MANAGEMENT  OF  NATURAL  LABOR.  281 

tion  takes  place,  and  then  reapply  the  pressure.  I  repeat  that,  after 
a  little  practice,  the  placenta  may  be  entirely  expelled  in  this  way, 
in  nineteen  cases  out  of  twenty,  Avithout  even  touching  the  cord, 
and  the  bugbear  of  retained  placenta  will  cease  to  be  a  source  of 
dread. 

Management  of  the  Membranes. — Should  we  fail  in  causing  the 
uterus  to  expel  the  placenta,  a  vaginal  examination  may  be  made, 
and,  if  the  placenta  be  found  lying  entirely  in  the  vagina,  it  may  be 
carefully  withdrawn.  If,  however,  the  cord  can  be  traced  up  through 
the  os,  showing  that  the  placenta  is  still  within  the  uterine  cavity, 
we  must  again  resort  to  pressure  to  effect  its  expulsion,  and  not  at- 
tempt to  withdraw  it  by  traction.  Such  cases  may  fairly  be  classed 
as  retained  placenta,  but  they  should  be  very  rarely  met  with,  and 
are  discussed  elsewhere.  When  they  do  occur  often  in  the  hands  of 
the  same  practitioner,  it  is  fair  to  conclude  that  he  has  not  properly 
acquired  the  art  of  managing  this  stage  of  labor.  Generally  speak- 
ing, the  placenta  should  be  expelled  within  twenty  minutes  after  the 
birth  of  the  child ;  but  no  doubt,  in  the  large  majority  of  cases, 
expulsion  might  be  effected  sooner  were  it  advisable  to  attempt  it. 

When  the  mass  of  the  placenta  is  expelled,  the  membranes  gen- 
erally still  remain  in  the  vagina,  and  they  should  be  twisted  into  a 
rope,  and  very  gently  withdrawn,  so  as  not  to  leave  any  portion  be- 
hind. The  risk  of  this  accident  will  be  lessened  if  the  placenta  is 
received  into  the  palm  of  the  right  hand,  on  expression,  so  as  to 
avoid  any  strain  on  the  membranes. 

Compression  of  the  Uterus  after  the  Expulsion  of  the  Placenta. — The 
duties  of  the  medical  attendant  are  not  even  now  over.  For  at  least 
ten  minutes  after  the  extrusion  of  the  placenta,  he  should  keep  his 
hand  on  the  firmly  contracted  uterus,  gently  kneading  it,  without 
any  force,  for  the  purpose  of  promoting  firm  and  equable  contraction, 
and  causing  it  to  throw  off  any  coagula  that  may  form  in  its  cavity. 

Administration  of  Ergot  of  Rye. — The  subsequent  comfort  and  safety 
of  the  patient  may  be  promoted  by  administering,  at  this  time,  a  full 
dose  of  ergot  of  rye,  such  as  a  drachm,  or  more,  of  the  liquid  extract. 
The  property  possessed  by  this  drug  of  producing  tonic  and  persistent 
contraction  of  the  uterine  fibres,  which  renders  it  of  doubtful  utility 
as  an  oxytocic  during  labor,  is  of  special  value  after  delivery,  when 
such  contraction  is  precisely  what  we  desire.  I  have  long  been  in 
the  habit  of  administering  the  drug  at  this  period,  and  believe  it  to 
be  of  great  value,  not  only  as  a  prophylactic  against  hemorrhage, 
but  as  a  means  of  lessening  after-pains. 

Application  of  the  Binder. — When  we  are  satisfied  that  the  uterus 
is  permanently  contracted  we  may  apply  the  binder,  but  this  should 
rarely  be  done  until  at  least  half  an  hour  after  the  birth  of  the  child. 
The  soiled  clothes  should  be  gently  withdrawn  from  under  the 
patient,  moving  her  as  little  as  possible,  and  the  binder  should  be, 
at  the  same  time,  slipped  under  the  body,  taking  care  that  it  is 
passed  well  below  the  hips,  so  as  to  secure  a  firm  hold.  No  kind  of 
bandage  is  better  than  a  piece  of  stout  jean,  of  sufficient  breadth  to 
extend  from  the  trochanters  to  the  ensiform  cartilage ;  a  jack-towel 
19 


282  LABOR. 

or  bolster  slip  answers  the  purpose  very  well.  These  are  preferable, 
at  any  rate  at  first,  to  the  shaped  binders  that  are  often  used.  One- 
or  two  folded  napkins  are  generally  placed  over  the  uterus,  so  as  to 
form  a  pad  to  keep  up  pressure.  Once  in  position,  the  binder  is 
pulled  tight,  and  fastened  by  pins.  The  utility  of  careful  bandaging 
after  delivery  can  scarcely  be  doubted,  although  some  years  ago  it 
became  the  fashion  to  dispense  with  it.  It  gives  a  comfortable  sup- 
port to  the  lax  abdominal  walls,  keeps  up  a  certain  amount  of  pres- 
sure on  the  uterus,  arid  tends  to  restore  the  figure  of  the  patient. 
After  the  bandage  is  applied,  a  warm  napkin  should  be  placed  on  the 
vulva,  as  a  means  of  estimating  .the  quantity  of  the  discharge,  and 
the  patient  may  be  allowed  to  rest. 

After-treatment. — Unless  the  labor  have  been  very  long  and  fatigu- 
ing, an  opiate,  often  exhibited  as  a  matter  of  routine,  is  unadvisable ; 
although  it  may  be  well  to  leave  one  with  the  nurse,  to  be  given  if 
the  patient  cannot  sleep,  or  if  the  after-pains  be  very  troublesome. 
The  practitioner  may  now  leave  the  room,  but  not  the  house,  and  at 
least  an  hour  should  elapse  after  delivery  before  he  takes  his  depart- 
ure. Before  doing  so  he  should  visit  the  patient,  inspect  the  napkin 
to  see  that  there  is  not  too  much  discharge,  and  satisfy  himself 
that  the  uterus  is  contracted,  and  not  distended  with  coagnla.  He 
should  also  count  the  pulse,  which,  if  the  patient  be  progressing 
satisfactorily,  will  be  found  at  its  normal  average.  If,  however,  it 
be  beating  over  100  per  minute,  he  should  on  no  account  leave,  for 
such  a  rapidity  of  the  circulation  renders  it  extremely  probable  that 
hemorrhage  is  impending.  This  is  a  good  practical  rule,  laid  down 
by  M'Clintock  in  his  excellent  paper  "On  the  Pulse  in  Child-bed," 
attention  to  which  may  often  save  the  patient  from  disastrous  con- 
sequences. 

Before  leaving,  the  practitioner  should  see  that  the  room  is  dark- 
ened, all  bystanders  excluded,  and  the  patient  left  as  quiet  as  possible 
to  recover  from  the  shock  of  labor. 


CHAPTER  IV. 

ANESTHESIA   IN  LABOR. 

A  FEW  words  may  be  said  as  to  the  use  of  anaesthetics  during 
labor,  a  practice  which  has  become  so  universal  that  no  argument  is 
required  to  establish  its  being  a  perfectly  legitimate  means  of  as- 
suaging the  sufferings  of  childbirth.  Indeed,  the  tendency  in  the 
present  day  is  in  the  opposite  direction ;  and  a  common  error  is  the 
administration  of  chloroform  to  an  extent  which  materially  interferes 


ANAESTHESIA    IN    LABOR.  283 

with  the  uterine  contractions,  and  predisposes  to  subsequent  post- 
partum  hemorrhage. 

Agents  Employed. — Practically  speaking,  the  only  agent  employed 
in  this  country  is  chloroform,  although  the  bi-chloride  of  methylene, 
and  ether,  have  been  occasionally  tried.  Of  late  years,  chloral  has 
been  extensively  used  by  some ;  and  as  I  believe  it  to  be  an  agent 
of  very  great  value,  I  shall  first  indicate  the  circumstances  under 
which  it  may  be  employed. 

Chloral. — The  peculiar  value  of  chloral  in  labor  is,  that  it  may  be 
safely  administered  at  a  time  when  chloroform  cannot  be  generally 
employed.  The  latter,  while  it  annuls  suffering,  very  frequently 
tends,  in  a  marked  degree,  to  diminish  uterine  action.  This  is  a 
familiar  observation  to  all  who  have  employed  it  much  during  labor, 
as  the  diminution  of  the  force  and  intensity  of  the  pains,  and  the 
consequent  retardation  of  the  labor,  often  oblige  us  to  suspend  its  in- 
halation, at  least  temporarily.  Indeed,  this  very  property  of  annul- 
ling uterine  action  is  one  of  its  most  valuable  qualities  in  obstetrics, 
as  in  certain  cases  of  turning.  For  such  purposes  it  is  necessary  to 
give  it  to  the  surgical  extent,  which  we  endeavor  to  avoid  when  it  is 
used  simply  to  lessen  the  suffering  of  ordinary  labor.  Still  it  is  not 
always  easy  to  limit  its  action  in  this  way,  and  thus  it  very  frequently 
does  more  than  we  wish.  Such  diminution  in  the  intensity  of  uterine 
con'traction  is  comparatively  of  less  consequence  in  the  propulsive 
stage,  and  it  is  generally  more  than  counterbalanced  by  the  relief  it 
affords.  In  the  first  stage  it  is  otherwise,  and,  practically  speaking, 
chloroform  is  generally  not  admissible  until  the  head  is  in  the  pelvic 
cavity. 

Chloral  on  the  other  hand,  has  no  such  relaxing  effects  on  uterine 
contraction.  It  cannot,  it  is  true,  compete  with  chloroform  in  its  power 
of  relieving  pain,  but  it  produces  a  drowsy  state  in  which  the  pain  is 
not  felt  nearly  so  acutely  as  before.  It  is,  therefore,  in  the  first  stage 
of  labor,  while  the  pains  are  cutting  and  grinding,  and  during  the 
dilatation  of  the  cervix,  that  it  finds  its  most  useful  application.  It 
is  especially  valuable  in  those  cases,  so  frequently  met  with  in  the 
upper  classes,  in  which  the  pains  produce  intolerably  acute  suffering, 
with  but  little  effect  on  the  progress  of  the  labor.  In  them  the  os  is 
often  thin  and  rigid,  and  the  pains  very  frequent  and  acute,  but  little 
or  no  dilatation  is  effected.  When  the  patient  is  brought  under  the 
influence  of  chloral,  however,  the  pains  become  less  frequent  but 
stronger,  nervous  excitement  is  calmed,  and  the  dilatation  of  the 
cervix  often  proceeds  rapidly  and  satisfactorily.  Indeed,  I  know  of 
nothing  which  answers  so  well  in  cases  of  rigid,  undilatable  cervixr 
and  I  believe  its  administration  to  be  far  more  effective,  under  such, 
circumstances,  than  any  of  the  remedies  usually  employed. 

Object  and  Mode  of  Administration. — The  object  is  to  produce  a 
somnolent  condition,  which  shall  be  protracted  as  long  as  possible. 
For  this  purpose  15  grains  of  chloral  may  be  administered  every 
twenty  minutes,  until  three  doses  are  given.  This  generally  suffices, 
to  produce  the  desired  effect.  The  patient  becomes  very  drowsyr 
dozes  between  the  pains,  and  wakes  up  as  each  contraction  com.:- 


284  LABOR. 

mences.  It  may  be  necessary  to  give  a  fourth  dose,  at  a  longer  in- 
terval, say  an  hour  after  the  third  dose,  to  keep  up  and  prolong  the 
soporific  action,  but  this  is  seldom  necessary,  and  I  have  rarely  given 
more  than  a  drachm  of  chloral  during  the  entire  progress  of  labor. 
Another  advantage  of  this  treatment  is  that,  while  it  does  not  inter- 
fere with  the  use  of  chloroform  in  the  second  stage,  it  renders  it 
necessary  to  give  less  than  otherwise  would  be  called  for,  and  thus 
its  action  can  be  more  easily  kept  within  bounds.  On  the  whole, 
therefore,  I  am  inclined  to  consider  chloral  a  very  valuable  aid  in  the 
management  of  labor,  and  believe  that  it  is  destined  to  be  much  more 
extensively  used  than  is  at  present  the  case.  So  far  as  my  experi- 
ence has  yet  gone  I  have  not  met  with  any  symptoms  which  have  led 
me  to  think  that  it  has  produced  bad  effects  ;  and  I  have  known 
many  patients  sleep  quietly  through  labor,  without  expressing  any 
excessive  suffering,  or  asking  for  chloroform,  who,  under  ordinary 
circumstances,  would  have  been  most  urgently  calling  for  relief. 

Chloroform. — Generally  speaking,  we  do  not  think  of  giving  chloro- 
form until  the  os  is  fully  dilated,  the  head  descending,  and  the  pains 
becoming  propulsive.  It  has  often,  indeed,  been  administered  earlier, 
for  the  purpose  of  aiding  the  dilatation  of  a  rigid  cervix,  and  there 
is  no  doubt  that  it  often  succeeds  well  when  employed  in  this  way ; 
but  I  have  already  stated  my  belief  that  chloral  answers  this  purpose 
better. 

Should  only  be  given  during  the  Pains. — There  is  one  cardinal 
rule  to  be  remembered  in  giving  chloroform  during  the  propulsive 
stage,  and  that  is,  that  it  should  be  administered  intermittently,  and 
never  continuously.  When  the  pain  comes  on  a  few  drops  may  be 
scattered  over  a  Skinner's  inhaler,  which  affords  one  of  the  best 
means  of  administering  it  in  labor,  or  placed  within  the  folds  of  a 
handkerchief  twisted  into  the  form  of  a  cone.  During  the  acme  of 
the  pain  the  patient  inhales  it  freely,  and  at  once  experiences  a  sense 
of  great  relief;  and,  as  soon  as  the  pain  dies  away,  the  inhaler  should 
be  removed.  In  the  interval  between  the  pains  the  effect  of  the  drug 
passes  off,  so  that  the  higher  degree  of  ansesthesia  should  never  be 
produced.  Indeed,  when  properly  given,  consciousness  should  not 
be  entirely  abolished,  and  the  patient,  between  the  pains,  should  be 
able  to  speak,  and  understand  what  is  said  to  her.  This  intermittent 
administration  constitutes  the  peculiar  safety  of  chloroform  admin- 
istered in  labor,  and  it  is  a  fortunate  circumstance  that,  as  yet,  there 
is,  I  believe,  no  case  on  record  of  death  during  the  inhalation  of 
chloroform  for  obstetric  purposes.  This  is  obviously  due  to  the 
effect  of  each  inhalation  passing  off  before  a  fresh  dose  is  admin- 
istered. 

The  effect  on  the  pains  should  be  carefully  watched.  If  they 
become  very  materially  lessened  in  force  and  frequency,  it  may  be 
necessary  to  stop  the  inhalation  for  a  short  time,  commencing  again 
when  the  pains  get  stronger,  which  effect  may  be  often  completely 
and  easily  prevented  by  mixing  the  chloroform  with  about  one-third 
of  absolute  alcohol,  which,  originally  recommended,  I  believe,  by 
Dr.  Sansom,  increases  the  stimulating  effects  of  the  chloroform,  and 


ANAESTHESIA    IX    LABOR.  285 

thus  diminishes  its  tendency  to  produce  undue  relaxation.  The 
amount  administered  must  vary,  of  course,  with  the  peculiarities  of 
each  individual  case  and  the  effect  produced,  bat  it  need  never  be 
large.  As  the  head  distends  the  perineum,  and  the  pains  get  very 
strong  and  forcing,  it  may  be  given  more  freely  and  to  the  extent  of 
inducing  even  complete  insensibility  just  before  the  child  is  born. 

Ether  as  a  Substitute  for  Chloroform. — In  cases  in  which  chloroform 
has  lessened  the  force  of  the  pains,  I  have,  of  late,  frequently  sub- 
stituted the  inhalation  of  ether  with  great  advantage.  It  certainly 
often  acts  well  when  chloroform  is  inadmissible  on  account  of  its 
effects  on  the  pains,  and,  so  far  as  rny  experience  goes,  it  has  not  the 
property  of  relaxing  the  uterus,  but,  on  the  contrary,  has  sometimes 
seemed  to  me  distinctly  to  intensify  the  pains. 

Precautions. — Bearing  in  mind  the  tendency  of  chloroform  to  pro- 
duce uterine  relaxation,  more  than  ordinary  precautions  should 
always  be  taken  against  post-partum  hemorrhage  in  all  cases  in 
which  it  has  been  freely  administered. 

In  cases  of  operative  midwifery  it  is  often  given  to  the  extent  of 
producing  complete  anaesthesia.  In  all  such  cases  it  should  be  admin- 
istered, when  possible,  by  another  medical  man,  and  not  by  the 
operator,  because  the  giving  of  chloroform  to  the  surgical  degree 
requires  the  undivided  attention  of  the  administrator,  and  no  man 
can  do  this  and  operate  at  the  same  time.  I  once  learnt  an  import 
ant  lesson  on  this  point.  I. had  occasion  to  apply  the  forceps  in  the 
case  of  a  lady  who  insisted  on  having  chloroform.  When  commenc- 
ing the  operation  I  noticed  some  suspicious  appearances  about  the 
patient,  who  was  a  large  stout  woman,  with  a  feeble  circulation.  I 
therefore  stopped,  allowed  her  to  regain  consciousness,  and  delivered 
her  without  anaesthesia,  much  to  her  own  annoyance.  Just  one  month 
after  labor  she  went  to  a  dentist  to  have  a  tooth  extracted,  and  took 
chloroform,  during  the  inhalation  of  which  she  died.  This  impressed 
on  my  mind  the  lesson  that  no  man  can  do  two  things  at  the  same 
time.  The  partial  unconsciousness  of  incomplete  anaesthesia,  in 
which  the  patient  is  restless  and  tossing  about,  renders  the  applica- 
tion of  forceps,  as  well  as  all  other  operations,  very  difficult.  There- 
fore, unless  the  patient  can  be  completely  and  fully  anaesthetized,  it 
is  better  to  operate  without  chloroform  being  given  at  all. 

[In  the  United  States  chloroform  is  rarely  used  in  obstetric  practice, 
as  compared  with  pure  sulphuric  ether,  such  as  that  prepared  by  Dr. 
Squibb,  of  New  York  ;  and  anaesthesia  is  much  less  frequently  prac- 
tised than  it  was  soon  after  its  introduction.  With  some  women, 
ether  acts  as  a  stimulant,  increasing  their  power  of  expulsion,  while 
at  the  same  time  the  suffering  is  greatly  lessened.  The  whole  pro- 
cess of  labor  is  perfect ;  the  placenta  is  extruded  almost  without 
blood,  and  there  is  no  subsequent  uterine  relaxation.  But  unfortu- 
nately such  cases  are  exceptional.  With  some  patients  the  anaesthetic 
produces  a  species  of  intoxication,  with  hysterical  excitement,  and 
the  pains,  which  are  at  first  diminished,  at  last  cease  entirely,  or  are 
rendered  of  no  value,  and  the  ether  has  to  be  withheld,  as  we  have 
frequently  seen.  Some  women  complain  that  they  have  a  night- 


286  LABOR. 

marc,  or  arc  made  to  "  feel  wild,"  and  are  not  relieved  of  pain,  and 
request  to  have  the  anaesthetic  withheld.  But  the  chief  cause  lor 
the  infrequent  resort  to  ether  has  been  the  production  of  uterine 
inertia  after  delivery,  and  consequent  post-partum  hemorrhage.  In 
turning,  the  remedy  is  for  the  time  important,  but  the  delivery  need 
not  be  completed  under  it.  The  use  of  fluid  ext.  ergot  is  a  valuable 
prophylactic,  but  more  to  be  relied  upon  in  most  instances  where  there 
has  been  no  anaesthesia. — ED.] 


CHAPTER  V. 

PELVIC  PRESENTATIONS. 

UNDER  the  head  of  pelvic  presentations  it  is  customary  to  include 
all  cases  in  which  any  part  of  the  lower  extremities  of  the  child  pre- 
sents. By  some  these  are  further  subdivided  into  breeth,  footling,  and 
knee  presentations ;  but,  although  it  is  of  consequence  to  be  able  to 
recognize  the  feet  and  the  knee  when  they  present,  so  far  as  the 
mechanism  and  management  of  delivery  are  concerned,  the  cases  are 
identical,  and,  therefore,  may  be  most  conveniently  considered  to- 
gether. 

frequency. — Presentations  coming  under  this  head  are  far  from 
uncommon ;  those  in  which  the  breech  alone  occupies  the  pelvis  are 
met  with,  according  to  Churchill,  once  in  52  labors,  while  Rams- 
botham  estimates  that  it  presents  more  frequently,  viz.,  once  in  38.8 
labors.  Footling  presentations  occur  only  once  in  92  cases.  They 
are  probably  often  the  mere  conversion  of  original  breech  presenta- 
tions, the  feet  having  come  down  during  the  labor,  either  in  conse- 
quence of  the  sudden  escape  of  the  liquor  amnii,  when  the  breech 
was  still  freely  movable  above  the  brim,  or  from  some  other  cause. 
Knee  presentations  are  extremely  rare,  as  may  be  readily  understood 
if  it  be  borne  in  mind  that  to  admit  them  the  thighs  must  be  ex- 
tended, hence  the  vertical  measurement  of  the  child  must  be  greatly 
increased,  and  therefore  it  could  not  be  readily  accommodated  within 
the  uterine  cavity,  unless  of  unusually  small  size.  As  a  matter  of 
fact,  Mme.  La  Chapelle  found  only  one  knee  presentation  in  upwards 
of  3000  cases. 

Causes. — The  causes  of  pelvic  presentations  are  not  known.  They 
are  probably  the  same  as  those  which  produce  other  varieties  of  mal- 
presentations ;  and  it  is  not  unlikely  that,  in  certain  women,  there 
may  be  some  peculiarity  in  the  shape  of  the  uterine  cavity  which 
favors  their  production.  It  would  be  difficult  otherwise  to  explain 
such  a  case  as  that  mentioned  by  Velpeau,  in  which  the  breech  pre- 
sented in  six  labors. 


PELVIC    PRESENTATIONS.  287 

Prognosis. — The  results,  as  regards  the  mother,  are  in  no  way  more 
unfavorable  than  in  vertex  presentation.  The  first  stage  of  the  labor 
is  generally  tedious,  since  the  large  rounded  mass  of  the  breech  does 
not  adapt  itself  so  well  as  the  head  to  the  lower  segment  of  the  uterus, 
and  dilatation  of  the  cervix  is  consequently  apt  to  be  retarded.  The 
second  stage  is,  however,  if  anything,  more  rapid  than  in  vertex 
cases ;  and  even  when  it  is  protracted,  the  soft  breech  does  not  pro- 
duce such  injurious  pressure  on  the  maternal  structures  as  the  hard 
and  u^delding  head. 

The  Infantile  Mortality  in  Pelvic  Presentations. — The  result  is  very 
different  as  regards  the  child.  Dubois  calculated  that  1  out  of  11 
children  was  still-born.  Churchill  estimates  the  mortality  as  much 
higher,  viz.,  1  in  S^th.  The  latter  certainly  indicates  a  larger  num- 
ber of  still-births  than  is  consistent  with  the  experience  of  most 
practitioners,  and  more  than  should  occur  if  the  cases  be  properly 
managed ;  but  there  can  be  no  doubt  that  the  risk  to  the  child  is, 
even  under  the  most  favorable  circumstances,  very  great.  Even  when 
the  child  is  not  lost  it  rnay  be  seriously  injured.  Dr.  Huge  has  tabu- 
lated a  series  of  29  cases  in  which  there  were  found  to  be  fractures  of 
bones  or  other  injuries.1 

Causes  of  foetal  Mortality. — The  chief  source  of  danger  is  pressure 
on  the  umbilical  cord,  in  the  interval  elapsing  between  the  birth  of 
the  body  and  the  head.  At  this  time  the  cord  is  very  generally  com- 
pressed between  the  head  of  the  child  and  the  pelvic  walls,  so  that 
circulation  in  its  vessels  is  arrested.  Hence  the  aeration  of  the  foetal 
blood  cannot  take  place ;  and,  pulmonary  respiration  not  having  been 
yet  established,  the  child  dies  asphyxiated.  There  are  other  condi- 
tions present  which  tend,  although  in  a  minor  degree,  to  produce  the 
same  result.  One  of  these  is  that  the  placenta  is  probably  often 
separated  by  the  uterine  contractions  when  the  bulk  of  the  body  is 
being  expelled,  as,  indeed,  takes  place,  under  analogous  circum- 
stances, when  the  vertex  presents  ;  the  necessary  result  being  the  arrest 
of  placental  respiration.  Joulin  thinks  that  the  same  effect  may  be 
produced  by  the  compression  of  the  placenta  between  the  contracted 
uterus  and  the  hard  mass  of  the  foetal  skull.  Probably  all  these 
causes  combine  to  arrest  the  functions  of  the  placenta;  and,  if  the 
delivery  of  the  head,  and  consequently  the  establishment  of  pulmo- 
nary respiration,  be  delayed,  the  death  of  the  child  is  almost  inevi- 
table. The  corollary  is  that  the  danger  to  the  child  is  in  direct 
proportion  to  the  length  of  time  that  elapses  between  the  birth  of 
the  body  and  that  of  the  head. 

The  risk  to  the  child  is  greater  in  footling  than  in  breech  cases, 
because  in  the  former  the  maternal  structures  are  less  perfectly  di- 
lated, in  consequence  of  the  small  size  of  the  feet  and  thighs,  and, 
therefore,  the  birth  of  the  head  is  more  apt  to  be  delayed. 

Diagnosis. — Inasmuch"  as  the  long  axis  of  the  child  corresponds 
with  the  long  axis  of  the  uterus,  in  pelvic  as  in  vertex  presentations, 
there  is  nothing  in  the  shape  of  the  uterus  to  arouse  suspicion  as  to 

1  Bui.  G6n.  de  Therap.,  August,  1875. 


LABOR. 

the  character  of  the  case.  Still,  it  is  often  sufficiently  easy  to  recog- 
nize a  pelvic,  presentation  by  abdominal  examination,  if  we  have 
occasion  to  make  one.  The  facility  with  which  it  may  be  done  de- 
pends a  good  deal  on  the  individual  patient.  If  she  bo  not  very 
stout,  and  if  the  abdominal  parietes  be  lax  and  non-resistant,  we 
shall  generally  be  able  to  feel  the  round  head  at  the  upper  part  of 
the  uterus  much  firmer,  and  more  defined  in  outline  than  the  breech. 
The  conclusion  will  be  fortified  if  we  hear  the  foetal  heart  beating  on 
a  level  with,  or  above,  the  umbilicus.  The  greater  resistance  on  one 
side  of  the  abdomen  will  also  enable  us  to  decide,  with  tolerable  ac- 
curacy, to  which  side  the  back  of  the  child  is  placed.  Information 
thus  acquired  is,  at  the  best,  uncertain ;  and  we  can  never  be  quite 
sure  of  the  existence  of  a  pelvic  presentation  until  we  can  corrobo- 
rate the  diagnosis  by  vaginal  examination. 

Results  of  Vaginal  Examination. — The  first  circumstance  to  ex- 
cite suspicion  on  examination  per  vayinam,  even  when  the  os  is  un- 
dilated,  is  the  absence  of  the  hard  globular  mass  felt  through  the 
lower  segment  of  the  uterus,  which  is  so  characteristic  of  vertex 
presentations.  When  the  os  is  sufficiently  open  to  allow  the  mem- 
branes to  protrude,  although  the  presenting  part  is  too  high  up  to  be 
within  reach,  we  may  be  struck  with  the  peculiar  shape  of  the  bag 
of  membranes,  which,  instead  of  being  rounded,  projects  a  consider- 
able distance  through  the  os,  like  the  finger  of  a  glove.  This  is  a 
peculiarity  met  with  in  all  malpresentations  alike,  and  is,  indeed, 
much  less  distinct  in  breech  than  in  footling  presentations,  because 
in  the  former  the  membranes  are  more  stretched,  just  as  they  are  in 
vertex  cases.  When  the  membranes  rupture,  instead  of  the  waters 
dribbling  away  by  degrees,  they  often  escape  with  a  rush,  in  conse- 
quence of  the  pelvic  extremity  not  filling  up  the  lower  part  of  the 
uterus  so  accurately  as  the  head,  which  acts  as  a  sort  of  ball-valve, 
and  prevents  the  sudden  and  complete  discharge  of  the  waters. 

Diagnosis  of  the  Breech. — Often,  on  first  examining,  even  when  the 
membranes  are  ruptured,  the  presentation  is  too  high  up  to  be  made 
out  accurately.  All  that  we  can  be  certain  of  is,  that  it  is  not  the 
head ;  and  the  case  must  be  carefully  watched,  and  examinations 
frequently  repeated,  until  the  precise  nature  of  the  presentation  can 
be  established.  If  the  breech  present,  the  finger  first  impinges  on  a 
round,  soft  prominence,  on  depressing  which  a  bony  protuberance, 
the  trochanter  major,  can  be  felt.  On  passing  the  finger  upwards  it 
reaches  a  groove,  beyond  which  a  similar  fleshy  mass,  the  other 
buttock,  can  be  felt.  In  this  groove  various  characteristic  points, 
diagnostic  of  the  presentation,  can  be  made  out.  Towards  one  end 
we  can  feel  the  movable  tip  of  the  coccyx,  and  above  it  the  hard 
sacrum,  with  rough  projecting  prominences.  These  points,  if  accu- 
rately made  out,  are  quite  characteristic,  and  resemble  nothing  in 
any  other  presentation.  In  front  there  is  the  anus,  in  which  it  is 
sometimes,  but  by  no  means  always,  possible  to  insert  the  tip  of  the 
finger.  If  this  can  be  done  it  is  easy  to  distinguish  it  from  the 
mouth,  with  which  it  might  be  confounded,  by  observing  that  the 
hard  alveolar  ridges  are  not  contained  within  it.  Still  more  in  front 


PELVIC    PRESENTATIONS.  280 

we  may  find  the  genital  organs,  the  scrotum  in  male  children  being 
often  much  swollen  if  the  labor  has  been  protracted.  Thus  it  is  often 
possible  to  recognize  the  sex  of  the  child  before  birth. 

Differential  Diagnosis. — The  breech  might  be  mistaken  for  the 
face,  especially  if  the  latter  be  much  swollen  ;  but  this  mistake  can 
readily  be  avoided  by  feeling  the  spinous  processes  of  the  sacrum. 

The  knee  is  recognized  by  its  having  two  tuberosities  with  a  de- 
pression between  them.  It  might  be  confounded  with  the  heel,  the 
elbowr,  or  the  shoulder.  From  the  heel,  it  is  distinguished  by  having 
two  tuberosities  instead  of  one  ;  from  the  elbow,  by  the  latter  having 
one  sharp  tuberosity,  with  a  depression  on  each  side,  instead  of  a 
central  depression  and  two  lateral  prominences ;  and  from  the 
shoulder,  by  the  latter  being  more  rounded,  having  only  one  promi- 
nence, running  from  which  the  acromion  and  clavicle  can  be  traced. 

Diagnosis  of  the  foot. — The  foot  may  be  mistaken  for  the  hand. 
This  error  will  be  avoided  by  remembering  that  all  the  toes  are  in 
the  same  line,  and  that  the  great  toe  cannot  be  brought  into  apposi- 
tion  with  the  others,  as  the  thumb  can  with  the  fingers.  The  internal 
border  of  the  foot  is  much  thicker  than  the  external,  whereas  the 
two  borders  of  the  hand  are  of  the  same  thickness.  Moreover,  the 
foot  is  articular  at  right  angles  to  the  leg,  and  cannot  be  brought 
into  a  line  with  it,  as  the  hand  can  with  the  arm.  Finally,  the  pro- 
jection of  the  calcaneum  is  characteristic,  and  resembles  nothing  in 
the  hand. 

Mechanism. — As  is  the  case  in  other  presentations,  obstetricians 
have  very  variously  subdivided  breech  presentations,  with  the  effect 
of  needlessly  complicating  the  subject.  The  simplest  division,  and 
that  which  will  most  readily  impress  itself  on  the  memory  of  the 
student,  is  to  describe  the  breech  as  presenting  in  four  positions, 
analogous  to  those  of  the  vertex,  the  sacrum  being  taken  as  repre- 
senting the  occiput,  and  the  positions  being  numbered  according  to 
the  part  of  the  pelvis  to  which  it  points.  Thus  we  have — 

First,  or  left  s  aero -anterior  (corresponding  to  the  first  position  ot 
the  vertex).  The  sacrum  of  the  child  points  to  the  left  foramen 
ovale  of  the  mother. 

Second,  or  right  sacro-anterior  (corresponding  to  the  second  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  foramen  ovale 
of  the  mother. 

Third,  or  right  sacro-posterior  (corresponding  to  the  third  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  sacro-iliac 
synchondrosis  of  the  mother. 

Fourth,  or  left  sacro-posterior  (corresponding  to  the  fourth  vertex 
position).  The  sacrum  of  the  child  points  to  the  left  sacro-iliac 
synchondrosis  of  the  mother. 

Of  these,  as  with  the  corresponding  vertex  positions,  the  first  and 
third  are  the  most  common,  their  comparative  frequency,  no  doubt, 
depending  on  the  same  causes.  The  mechanical  conditions  to  which 
the  presenting  part  is  subjected  are  also  identical,  but  the  alterations 
of  positions  of  the  breech  in  its  progress  are  by  no  means  so  uniform 
as  those  of  the  head,  on  account  of  its  less  perfect  adaptation  to  the 


200 


LABOR. 


pelvic  cavity.  The  mechanism  of  the  delivery  of  the  shoulders  and 
head  in  breech  presentations,  moreover,  is  of  much  greater  practical 
importance  than  that  of  the  body  in  vertex  presentations,  inasmuch 
as  the  safety  of  the  child  depends  on  its  speedy  and  satisfactory  ac- 
complishment. Bearing  these  facts  in  mind,  it  will  suffice  to  describe 
briefly  the  phenomena  of  delivery  in  the  first  and  third  breech 
positions. 

FIG.  104. 


First  or  left  Sacro-cotyloid  Position  of  the  Breech. 


Position  of  the  Child  at  Brim. — In  the  first  position  the  sacrum  of 
the  child  points  to  the  left  foramen  ovale  ,  its  back  is  consequently 
placed  to  the  left  side  of  the  uterus  and  anteriority,  and  its  abdomen 
looks  to  the  right  side  of  the  uterus  and  posteriorly.  The  sulcus  ^ 
between  the  buttocks  lies  in  the  right  oblique  diameter  of  the  pelvis, 
while  the  transverse  diameter  of  the  buttocks  lies  in  the  left  oblique 
diameter,  the  left  buttock  being  most  easily  within  reach.  As  in 
vertex  presentations  the  hips  of  the  child  lie  on  the  same  level  at 
the  pelvic  brim,  although  Naegele  describes  the  left  hip  as  placed 
lower  than  the  right. 

Descent. — As  the  pains  act  on  the  body  of  the  child,  the  breech 
is  gradually  forced  through  the  pelvic  cavity,  retaining  the  same 
relations  as  at  the  brim,  its  progress  being  generally  more  slow  than 
that  of  the  head,  until  it  reaches  the  lower  pelvic  strait,  when  the 
same  mechanism  which  produces  rotation  of  the  occiput  comes  to 
operate  upon  it.  The  result  is  a  rotation  of  the  child's  pelvis,  so 
that  its  transverse  diameter  comes  to  lie  approximately  in  the  antero- 
posterior  diameter  of  the  outlet,  its  antero-posterior  diameter  corre- 
sponds to  the  transverse  diameter  of  the  mother's  pelvis,  the  left  hip 
lies  behind  the  pubis,  and  the  right  towards  the  sacrum.  This  rota- 


PELVIC    PRESENTATIONS. 

tion,  which  is  admitted  by  the  majority  of  obstetricians,  is  altogether 
denied  by  JSTaegele.  There  can  be  no  doubt,  however,  that  it  does 
generally  take  place,  but  by  no  means  so  constantly  as  the  corre- 
sponding rotation  of  the  vertix ;  and  it  is  not  uncommon  for  it  to 
be  entirely  absent,  and  for  the  hips  to  be  born  in  the  oblique  diam- 
eter of  the  outlet.  The  body  of  the  child  is  said  frequently  not 
to  follow  the  movement  imparted  to  the  hips,  so  that  there  is  more 
or  less  of  a  twist  in  the  vertebral  column. 

Expulsion  of  the  Hips  and  Body. — The  left  hip  now  becomes  firmly 
fixed  behind  the  pubis,  and  a  movement  of  extension,  analogous  to 
that  of  the  head  in  vertex  presentations,  takes  place.  The  right,  or 
posterior,  hip  revolves  round  the  fixed  one,  gradually  distends  the 
perineum,  and  is  expelled  first,  the  left  hip  rapidly  following.  As 
soon  as  both  hips  are  born,  the  feet  slip  out,  unless  the  legs  are  com- 
pletely extended  upon  the  child's  abdomen.  The  shoulders  soon 
follow,  lying  in  the  left  oblique  diameter  of  the  pelvis.  The  left 
shoulder  rotates  forwards  behind  the  pubis,  where  it  becomes  fixed, 
the  right  shoulder  sweeping  over  the  perineum,  and  being  born 
first.  The  arms  of  the  child  are  generally  found  placed  upon  its 
thorax,  and  are  born  before  the  shoulders.  Sometimes  they  are  ex- 
tended over  the  child's  head,  thus  causing  considerable  delay,  and 
greatly  increasing  the  risk  to  the  child.  It  is  now  generally  ad- 
mitted that  such  extension  is  most  apt  to  occur  when  traction  has 
been  made  on  the  child's  body  with  the  view  of  hastening  delivery, 
and  that  it  is  rarely  met  with  when  the  expulsion  of  the  body  is  left 
entirely  to  the  natural  powers. 

Delivery  of  the  Head. — When  the  shoulders  are  expelled  the  head 
enters  the  pelvis  in  the  opposite,  or  right  oblique  diameter,  the  face 
looking  to  the  right  sacro-iliac  synchondrosis.  As  the  greater  part 

FIG.  105. 


Passage  of  the  Shoulders  and  Partial  Rotation  of  the  Thorax. 

of  the  child  is  now  expelled,  and  as  the  head  has  entered  the  vagina, 
the  uterus,  having  a  comparatively  small  mass  to  contract  upon, 
must  obviously  act  at  a  mechanical  disadvantage.  Still  the  pressure 
of  the  head  on  the  vagina  is  a  powerful  inciter,  the  accessory  muscles 


292  LABOR. 

of  parturition  are  brought  into  strong  action,  and  there  is  usually 
quite  sufficient  force  to  insure  expulsion  of  the  head  without  artificial 
aid.  On  account  of  the  great  resistance  to  the  descent  of  the  occiput 
from  its  articulation  with  the  spinal  column,  the  pains  have  the 

FIG.  106. 


Descent  of  the  Head. 


effect  of  forcing  down  the  anterior  portion  of  the  head,  and  this 
insures  the  complete  flexion  of  the  chin  upon  the  sternum.  This  is 
a  great  advantage  from  a  mechanical  point  of  view,  as  it  causes  the 
short  occipito  mental  diameter  of  the  head  to  enter  the  pelvis  in  the 
axis  of  the  uterus  and  the  brim.  If  the  head  should  be  in  a  state 
of  partial  extension — as  sometimes  happens  when  the  pelvis  is  un- 
usually roomy — the  occipital  frontal  diameter  is  placed  in  a  similar 
relation  to  the  brim,  a  position  certainly  less  favorable  to  the  easy 
birth  of  the  head.  As  the  head  descends  it  experiences  a  movement 
of  rotation,  the  occiput  passing  forwards  and  to  the  right,  behind  the 
pubic  arch,  the  face  turning  backwards  into  the  hollow  of  the  sacrum. 
The  body  of  the  child  will  be  observed  to  follow  this  movement,  so 
that  its  back  is  turned  towards  the  mother's  abdomen,  its  anterior 
surface  to  the  perineum.  The  nape  of  the  neck  now  becomes  firmly 
fixed  under  the  arch  of  the  pubis,  the  pains  act  chiefly  on  the  ante- 
rior portion  of  the  head,  and  cause  it  to  sweep  over  the  perineum, 
the  chin  being  first  born,  then  the  mouth  and  forehead,  and  lastly 
the  occiput. 

Sacro-posterior  Positions. — It  is  needless  to  describe  the  differences 
between  the  mechanism  of  the  second  and  first  positions,  which  the 
student,  who  has  mastered  the  subject  of  vertex  presentations,  will 
readily  understand.  It  is  necessary,  however,  to  say  a  few  words  as 
to  sacro- posterior  positions,  choosing  for  that  purpose  the  third,  which 
is  the  more  common  of  the  two.  This  is  exactly  the  opposite  of  the 
first  position.  The  sacrum  of  the  child  points  to  the  right  sacro- 
iliac  synchondrosis,  its  abdomen  looks  forward  and  to  the  left  side 
of  the  mother.  The  transverse  diameter  of  the  child's  pelvis  lies  in 
the  left  oblique  diameter,  the  right  hip  being  anterior.  The  birth  of 


PELVIC    PRESENTATIONS.  203 

the  body  generally  takes  place  exactly  in  the  way  that  has  been 
already  described,  the  right  hip  being  towards  the  pubis. 

As  the  head  descends  into  the  pelvis  the  occiput  most  usually 
rotates  along  its  right  side — the  rotation  having  been  often  already 
partially  effected  when  that  of  the  hips  had  been  made — until  it  comes 
to  rest  behind  the  pubis,  the  face  passing  backwards  along  the  left 
side  of  the  pelvis  into  the  hollow  of  the  sacrum.  This  change  cor- 
responds exactly  to  the  anterior  rotation  of  the,  occiput  in  occipito- 
posterior  positions,  and  is  the  natural  and  favorable  termination. 

Sometimes,  forward  rotation  does  not  take  place,  and  the  occiput 
then  turns  backwards  into  the  hollow  of  the  sacrum.  What  then 
generally  occurs  is  that  the  pains  continue,  for  the  reason  already 
mentioned,  to  depress  the  chin  and  produce  strong  flexion  of  the  face 
on  the  sternum,  the  occiput  becoming  fixed  on  the  anterior  border 
of  the  perineum.  The  pains  continuing  to  act  chiefly  on  the  anterior 
part  of  the  head,  the  face  is  born  first  behind  the  pubis,  the  occiput 
only  slipping  over  the  perineum  after  the  forehead  has  been  ex- 
pelled. 

Second  Mode  in  ichich  such  Cases  occasionally  End. — A  second  mode 
of  termination  of  such  positions  is  mentioned  in  most  works,  on  the 
authority  of  one  or  two  recorded  cases ;  but  although  mechanically 
possible,  it  is  certainly  an  event  of  extreme  rarity.  The  chin,  in- 
stead of  being  flexed  on  the  sternum,  is  greatly  extended,  so  that 
the  face  of  the  child  looks  upwards  towards  the  pelvic  brim.  The 
chin  then  hitches  over  the  upper  edge  of  the  pubis  and  becomes  fixed 
there,  while  the  force  of  the  uterine  contractions  is  expended  on  the 
posterior  part  of  the  head,  which  descends  through  the  pelvis,  dis- 
tending the  perineum,  and  is  born  first,  the  face  subsequently  fol- 
lowing. 

Mechanism  of  Feet  Presentation. — The  mechanism  of  the  delivery 
of  the  body  and  head  in  cases  in  which  the  feet  originally  present, 
does  not  differ,  in  any  important  respect,  from  that  which  has  been 
already  described,  and  requires  no  separate  notice. 

Treatment. — From  what  has  been  said  of  the  natural  mechanism, 
it  is  evident  that  one  of  the  most  fruitful  causes  of  difficulty  and 
complication  is  undue  interference  on  the  part  of  the  practitioner. 
It  is,  no  doubt,  tempting  to  use  traction  on  the  partially  born  trunk 
in  the  hope  of  expediting  delivery ;  but  when  it  is  remembered  that 
this  is  almost  certain  to  produce  extension  of  the  arms  above  the 
head,  and  subsequently  extension  of  the  occiput  on  the  spine,  both 
of  which  seriously  increase  the  difficulty  of  delivery,  the  necessity 
of  leaving  the  case  as  much  as  possible  to  nature  will  be  apparent. 

Having  once,  therefore,  determined  the  existence  of  a  pelvic  pre- 
sentation, nothing  more  should  be  done  until  the  birth  of  the  breech. 
The  membranes  should  be  even  more  carefully  prevented  from  pre- 
maturely rupturing  than  in  vertex  presentations,  since  they  serve  to 
dilate  the  genital  passages  better  than  the  presenting  part.  Hence 
they  should  be  preserved  intact,  if  possible,  until  they  reach  the  floor 
of  the  pelvic,  instead  of  being  punctured  as  soon  as  the  os  is  fully 


294  LABOR. 

dilated.     The  breecli  when  born  should  be  received  and  supported 
in  the  palm  of  the  hand. 

Danger  to  Child. — When  the  body  is  expelled  as  far  as  the  umbili- 
cus, the  dangers  to  the  child  commence ;  for  now  the  cord  is  apt  to 
be  pressed  between  the  body  of  the  child  and  the  pelvic  walls.  To 
obviate  this  risk  as  much  as  possible,  a  loop  of  the  cord  should  be 
pulled  down,  and  carried  to  that  part  of  the  pelvis  where  there  is 
most  room,  which  will  generally  be  opposite  one  or  the  other  sacro- 
iliac  synchondrosis.  As  long  as  the  cord  is  freely  pulsating  we  may 
be  satisfied  that  the  life  of  the  child  is  not  gravely  imperilled,  al- 
though delay  is  fraught  with  danger,  from  other  sources  which  have 
been  already  indicated.  In  most  cases  the  arms  now  slip  out ;  but 
it  may  happen,  even  without  any  fault  on  the  part  of  the  accoucheur, 
that  they  are  extended  above  the  head,  and  it  is  of  great  importance 
that  we  should  be  thoroughly  acquainted  with  the  best  means  of 
liberating  them  from  their  abnormal  position. 

Management  when  the  Arms  are  extended  above  the  Head. — They 
must,  of  course,  never  be  drawn  directly  downwards,  or  the  almost 
certain  result  would  be  fracture  of  the  fragile  bones.  We  should 
endeavor  to  make  the  arm  sweep  over  the  face  and  chest  of  the  child, 
so  that  the  natural  movements  of  its  joints  should  not  be  opposed. 
If  the  shoulders  be  within  easy  reach,  the  finger  of  the  accoucheur 
should  be  slipped  over  that  which  is  posterior — because  there  is 
likely  to  be  more  space  for  this  manoeuvre  towards  the  sacrum — 
and  gently  carried  downwards  towards  the  elbow,  which  is  drawn 
over  the  face,  and  then  onwards,  so  as  to  liberate  the  forearm.  The 
same  manoeuvre  should  then  be  applied  to  the  opposite  arm.  It  may 
be  that  the  shoulders  are  not  easily  reached,  and  then  they  may  be 
depressed  by  altering  the  position  of  the  child's  body.  If  this  be 
carried  well  up  to  the  mother's  abdomen,  the  posterior  shoulder  will 
be  brought  lower  down  ;  and,  by  reversing  this  procedure  and  carry- 
ing the  body  back  over  the  perineum,  the  anterior  shoulder  may  be 
similarly  depressed.  It  is  only  very  exceptionally,  however,  that 
these  expedients  are  required. 

Birth  of  the  Head. — The  arms  being  extracted,  some  degree  of  ar- 
tificial assistance  is,  at  this  time,  almost  .always  required.  If  there 
be  much  delay,  the  child  will  almost  certainly  perish.  Attempts 
have  been  made,  in  cases  in  which,  delivery  of  the  head  could  not 
be  rapidly  effected,  to  established  pulmonary  respiration  by  passing 
one  or  two  fingers  into  the  vagina,  so  as  to  press  it  back  and  admit 
air  to  the  child's  mouth,  or  by  passing  a  catheter  or  tube  into  the 
mouth.  Neither  of  these  expedients  are  reliable,  and  we  should 
rather  seek  to  aid  nature  in  completing  the  birth  of  the  head  as  rap- 
idly as  possible.  The  first  thing  to  do,  supposing  the  face  to  have 
rotated  into  the  cavity  of  the  sacrum,  is  to  carry  the  body  of  the 
child  well  up  towards  the  pubis  and  abdomen  of  the  mother  without 
applying  any  traction,  for  fear  of  interfering  with  the  all-important 
flexion  of  the  chin  on  the  sternum.  If  now  the  patient  bear  down 
strongly,  the  natural  powers  may  be  sufficient  to  complete  delivery. 
If  there  be  any  delay,  traction  must  be  resorted  to,  and  we  must  en- 


PELVIC    PRESENTATIONS.  295 

deavor  to  apply  it  in  such  a  way  as  to  insure  flexion.  For  this  pur- 
pose, while  the  body  of  the  child  is  grasped  by  the  left  hand,  and 
drawn  upwards  towards  the  mother's  abdomen,  the  index  and  middle 
fingers  of  the  right  hand  are  placed  on  the  back  of  the  child's  neck, 
so  that  their  tips  press  on  either  side  of  the  base  of  the  occiput,  and 
push  the  head  into  a  state  of  flexion.  In  most  works  we  are  advised 
to  pass  the  index  and  middle  fingers  of  the  left  hand  at  the  same 
time  over  the  child's  face,  so  as  to  depress  the  superior  maxilla.  Dr. 
Barnes  insists  that  this  is  quite  unnecessary,  and  that  extraction  in 
the  manner  indicated,  by  pressure  on  the  occiput,  is  quite  sufficient. 
Should  it  not  prove  so,  flexion  of  the  chin  may  be  very  effectually 
assisted  by  downward  pressure  on  the  forehead  through  the  rectum. 
One  or  two  fingers  of  the  left  hand  can  readily  be  inserted  into  the 
bowel,  and  the  expulsion  of  the  head  is  thus  materially  facilitated. 

Value  of  Pressure  through  the  Abdomen.— By  far  the  most  power- 
ful aid,  however,  in  hastening  delivery  of  the  head,  should  delay 
occur,  is  pressure  from  above.  This  has  been,  strangely  enough, 
almost  altogether  omitted  by  writers  on  the  subject.  It  has  been 
strongly  recommended  by  Professor  Penrose,  and  there  can  be  no 
question  of  its  utility.  Indeed,  as  the  uterus  contracts  tightly  round 
the  head,  uterine  expression  can  be  applied  almost  directly  to  the 
head  itself,  and  without  any  fear  of  deranging  its  proper  relation  to 
the  maternal  passages.  It  is  very  seldom,  indeed,  that  a  judicious 
combination  of  traction  on  the  part  of  the  accoucheur,  with  firm 
pressure  through  the  abdomen  applied  by  an  assistant,  will  fail  in 
effecting  delivery  of  the  head  before  the  delay  has  had  time  to  prove 
injurious  to  the  child. 

Application  of  the  Forceps  to  the  After- coming  Head. — Many  accou- 
cheurs— among  others  Meigs,  and  Rigby — advocate  the  application 
of  the  forceps  when  there  is  delay  in  the  birth  of  the  after-coming 
head.  If  the  delay  be  due  to  want  of  expulsive  force  in  a  pelvis  of 
normal  size,  manual  extraction,  in  the  manner  just  described,  will  be 
found  to  be  sufficient  in  almost  every  case,  and  preferable,  as  being 
more  rapid,  easier  of  execution,  and  safer  to  the  child.  The  forceps 
may  be  quite  properly  tried,  if  other  means  have  failed ;  especially 
if  there  be  some  disproportion  between  the  size  of  the  head  and  the 
pelvis. 

Management  of  Sacro-posterior  Positions. — Difficulties  in  delivery 
may  also  occur  in  sacro-posterior  positions.  Up  to  the  time  of  the 
birth  of  the  head  the  labor  usually  progresses  as  readily  as  in  sacro- 
anterior  positions.  If  the  forward  rotation  of  the  hips  do  not  take 
place,  much  subsequent  difficulty  may  be  prevented  by  gently  favor- 
ing it  by  traction  applied  to  the  breech  during  the  pains,  the  finger 
being  passed  for  this  purpose  into  the  fold  of  the  groin. 

It  is  after  the  birth  of  the  shoulders  that  the  absence  of  rotation  is 
most  likely  to  prove  troublesome.  It  has  been  recommended  that 
the  body  should  then  be  grasped,  in  the  interval  between  the  pains, 
and  twisted  round  so  as  to  bring  the  occiput  forward.  It  is  by  no 
means  certain,  however,  that  the  head  would  follow  the  movement 
imparted  to  the  body,  and  there  must  be  a  serious  danger  of  giving 


296  LABOR. 

a  fatal  twist  of  the  neck  by  such  a  manoeuvre.  The  better  plan  is  to 
direct  the  face  backwards,  towards  the  cavity  of  the  sacrum,  by 
pressing  on  the  anterior  temple  during  the  continuance  of  a  pain. 
In  this  way  the  proper  rotation  will  generally  be  effected  without 
much  difficulty,  and  the  case  will  terminate  in  the  usual  way. 

Management  of  Cases  in  which  Forward  Rotation  does  not  occur. — If 
rotation  of  the  occiput  forwards  do  not  occur,  it  is  necessary  for  the 
practitioner  to  bear  in  mind  the  natural  mechanism  of  delivery  under 
such  circumstances.  In  the  majority  of  cases  the  proper  plan  is  to 
favor  flexion  of  the  chin  by  upward  pressure  on  the  occiput,  and  to 
exert  traction  directly  backwards,  remembering  that  the  nape  of  the 
neck  should  be  fixed  against  the  anterior  margin  of  the  perineum. 
If  this  be  not  remembered,  and  traction  be  made  in  the  axis  of  the 
pelvic  outlet,  the  delivery  of  the  head  will  be  seriously  impeded.  In 
the  rare  cases  in  which  the  head  becomes  extended,  and  the  chin 
hitches  on  the  upper  margin  of  the  pubis,  traction  directly  forwards 
and  upwards  may  be  required  to  deliver  the  head  ;  but  before  resort- 
ing to  it  care  should  be  taken  to  ascertain  that  backward  extension 
of  the  head  has  really  taken  place. 

Management  of  Impacted  Breech  Presentations. — It  remains  for  us 
to  consider  the  measures  which  may  be  adopted  in  those  very 
troublesome  cases  in  which  the  breech  refuses  to  descend,  and  be- 
comes impacted  in  the  pelvic  cavity,  either  from  uterine  inertia,  or 
from  disproportion  between  the  breech  and  the  pelvis.  Here,  un- 
fortunately, the  peculiar  shape  of  the  presenting  part,  which  is  un- 
adapted  for  the  application  of  the  forceps,  renders  such  cases  very 
difficult  to  manage. 

Two  measures  have  been  chiefly  employed  :  1st,  bringing  down 
one  or  both  feet,  so  as  to  break  up  the  presenting  part,  and  convert 
it  into  a  footling  case ;  2d,  traction  on  the  breech,  either  by  the 
fingers,  a  blunt  hook,  or  fillet  passed  over  the  groin. 

Barnes  insists  on  the  superiority  of  the  former  plan,  and  there  can 
be  no  question  that,  if  a  foot  can  be  got  down,  the  accoucheur  has  a 
complete  control  over  the  progress  of  the  labor,  which  he  can  gain 
in  no  other  way.  If  the  breech  be  arrested  at  or  near  the  brim,  there 
will  generally  be  no  great  difficulty  in  effecting  the  desired  object. 
It  will  be  necessary  to  give  chloroform  to  the  extent  of  complete 
anaesthesia,  and  to  pass  the  hand  over  the  child's  abdomen  in  the 
same  manner,  and  with  the  same  precautions,  as  in  performing  podalic 
version,  until  a  foot  is  reached,  which  is  seized  and  pulled  down.  If 
the  feet  be  placed  in  the  usual  way  close  to  the  buttocks,  no  great 
difficulty  is  likely  to  be  experienced.  If,  however,  the  legs  be  ex- 
tended on  the  abdomen,  it  will  be  necessary  to  introduce  the  hand 
and  arm  very  deeply,  even  up  to  the  fundus  of  the  uterus,  a  proced- 
ure which  is  always  difficult,  and  which  may  *be  very  hazardous. 
Nor  do  I  think  that  the  attempt  to  bring  down  the  feet  can  be  safe 
when  the  breech  is  low  down  and  fixed  in  the  pelvic  cavity.  A 
certain  amount  of  repression  of  the  breech  is  possible,  but  it  is 
evident  that  this  cannot  be  safely  attempted  when  the  breech  is  at 
all  low  down. 


PRESENTATIONS    OF    THE    FACE.  297 

Traction  on  the  Groin. — Under  such  circumstances  traction  is  our 
only  resource,  and  this  is  always  difficult  and  often  unsatisfactory. 
Of  all  contrivances  for  this  purpose  none  is  better  than  the  hand  of 
the  accoucheur.  The  index  finger  can  generally  be  slipped  over  the 
groin  without  difficulty,  and  traction  can  be  applied  during  the 
pains.  Failing  this,  or  when  it  proves  insufficient,  an  attempt  should 
be  made  to  pass  a  fillet  over  the  groins.  A  soft  silk  handkerchief, 
or  a  skein  of  worsted,  answers  best,  but  it  is  by  no  means  easy  to 
apply.  The  simplest  plan,  and  one  which  is  far  better  than  the  ex- 
pensive instruments  contrived  for  the  purpose,  is  to  take  a  stout 
piece  of  copper  wire  and  bend  it  double  into  the  form  of  a  hook. 
The  extremity  of  this  can  generally  be  guided  over  the  hips,  and 
through  its  looped  end  the  fillet  is  passed.  The  wire  is  now  with- 
drawn, and  carries  the  fillet  over  the  groins.  I  have  found  this 
simple  contrivance,  which  can  be  manufactured  in  a  few  moments, 
very  useful,  and  by  means  of  such  a  fillet  very  considerable  tractive 
force  can  be  employed.  The  use  of  a  soft  fillet  is  in  every  way  pre- 
ferable to  the  blunt  hook  which  is  contained  in  most  obstetric  bags. 
A  hard  instrument  of  this  kind  is  quite  as  difficult  to  apply,  and  any 
strong  traction  employed  by  it  is  almost  certain  to  seriously  injure 
the  delicate  fcetal  structures  over  which  it  is  placed.  As  an  auxiliary 
the  employment  of  uterine  expression  should  not  be  forgotten,  since 
it  may  give  material  aid  when  the  difficulty  is  only  due  to  uterine 
inertia. 

Embryotomy. — Failing  all  endeavors  to  deliver  by  these  expedients, 
there  is  no  resource  left  but  to  break  up  the  presenting  part  by  scis- 
sors, or  by  craniotomy  instruments ;  but  fortunately  so  extreme  a 
measure  is  but  rarely  necessary. 


CHAPTER  VI. 

PRESENTATIONS   OF   THE   FACE. 

PRESENTATIONS  of  the  face  are  by  no  means  rare ;  and,  although 
in  the  great  majority  of  cases  they  terminate  satisfactorily  by  the 
unassisted  powers  of  nature,  yet  every  now  and  again  they  give  rise 
to  much  difficulty,  and  then  they  may  be  justly  said  to  be  amongst 
the  most  formidable  of  obstetric  complications.  It  is,  therefore, 
essential  that  the  practitioner  should  thoroughly  understand  the 
natural  history  of  this  variety  of  presentation,  with  the  view  of 
enabling  him  to  intervene  with  the  best  prospect  of  success. 

Erroneous  Views  formerly  held  on  the  Subject. — The  older  accou- 
cheurs held  very  erroneous  views  as  to  the  mechanism  and  treatment 
20 


298  LABOR. 

of  these  cases,  most  of  them  believing  that  delivery  was  impossible 
by  the  natural  eftbrts,  and  that  it  was  necessary  to  intervene  by 
version  in  order  to  effect  delivery.  Smellie  recognized  the  fact  that 
spontaneous  delivery  is  possible,  and  that  the  chin  turns  forwards 
and  under  the  pubis;  but  it  was  not  until  long  after  his  time,  and 
chiefly  after  the  appearance  of  Mme.  La  Chapelle's  essay  on  the 
subject,  that  the  fact  that  most  cases  could  be  naturally  delivered 
was  fully  admitted  and  acted  upon. 

Frequency. — The  frequency  of  face  presentations  varies  curiously  in 
different  countries.  Thus,  Collins  found  that  in  the  Rotunda  Hos- 
pital there  was  only  1  case  in  497  labors,  although  Churchill  gives 
1  in  249  as  the  average  frequency  in  British  practice;  while  in  Ger- 
many this  presentation  is  met  with  once  in  169  labors.  The  only 
reasonable  explanation  of  this  remarkable  difference  is,  that  the 
dorsal  decubitus,  generally  followed  abroad,  favors  the  transforma- 
tion of  vertex  presentations  into  those  of  the  face. 

The  mode  in  which  this  change  is  effected — for  it  can  hardly  be 
doubted  that,  in  the  large  majority  of  cases,  face  presentation  is  due 
to  a  backward  displacement  of  the  occiput  after  labor  has  actually 
commenced,  but  before  the  head  has  engaged  in  the  brim — has  been 
made  the  subject  of  various  explanations. 

Mode  in  which  Face  Presentations  are  produced. — It  has  generally 
been  supposed  that  the  change  is  induced  by  a  hitching  of  the 
occiput  on  the  brim  of  the  pelvis,  so  as  to  produce  extension  of 
the  head,  and  descent  of  the  face ;  the  occurrence  being  favored  by 
the  oblique  position  of  the  uterus  so  frequently  met  with  in  preg- 
nancy. Hecker  attaches  considerable  importance  to  a  peculiarity 
in  the  shape  of  the  fcetal  head  generally  observed  in  face  pre- 
sentations, the  cranium  having  the  dolicho-cephalous  form,  promi- 
nent posteriorly,  with  the  occiput  projecting,  which  has  the  effect  of 
increasing  the  length  of  the  posterior  cranial  lever  arm,  and  facili- 
tating extension  when  circumstances  favoring  it  are  in  action.  Dr. 
Duncan1  thinks  that  uterine  obliquity  has  much  influence  in  the 
production  of  face  presentation,  but  in  a  different  way  from  that 
above  referred  to.  He  points  out  that,  when  obliquity  is  verv 
marked,  a  curve  in  the  genital  passages  is  produced,  the  convexitv 
of  which  is  directed  to  the  side  towards  which  the  uterus  is  deflected. 
When  uterine  contraction  commences,  the  foetus  is  propelled  down- 
wards, and  the  concavity  of  the  curve  is  acted  on  to  the  greatest  ad- 
vantage by  the  propelling  force,  and  tends  to  descend.  Should  the 
occiput  happen  to  lie  in  the  convexity  of  the  curve  so  formed,  the 
tendency  will  be  for  the  forehead  to  descend.  In  the  majority  of 
cases  its  descent  will  be  prevented  by  the  increased  resistance  it 
meets  with,  in  consequence  of  the  greater  length  of  the  anterior  cra- 
nial lever  arm ;  but  if  the  uterine  obliquity  be  extreme,  this  may 
be  counterbalanced,  and  a  face  presentation  ensues.  The  influence 
of  this  obliquity  is  corroborated  by  the  observation  of  Baudelocque, 
that  the  occiput  in  face  presentations  almost  invariably  corresponds 
to  the  side  of  the  uterine  obliquity.  A  further  corroboration  is 

1  Kilin.  Med.  Jour.,  vol.  xv. 


PRESENTATIONS    OF    THE    FACE.  299 

afforded  by  the  fact,  that  in  face  presentation  the  occiput  is  much 
more  frequently  directed  to  the  right  than  to  the  left  ;  while  right 
lateral  obliquity  of  the  uterus  is  also  much  more  common. 

These  theories  assume  that  face  presentations  are  produced  during 
labor.  In  a  few  cases  they  certainly  exist  before  labor  has  com- 
menced. It  is  possible,  however,  as  we  know  that  uterine  contrac- 
tions exist  independently  of  actual  labor,  that  similar  causes  may 
also  be  in  operation,  although  less  distinctly,  before  the  commence- 
ment of  labor. 

Diagnosis. — The  diagnosis  is  often  a  matter  of  considerable  diffi- 
culty at  an  early  period  of  labor,  before  the  os  is  fully  dilated  and 
the  membranes  ruptured,  and  when  the  face  has  not  entered  the 
pelvic  cavity.  The  finger  then  impinges  on  the  rounded  mass  of  the 
forehead,  which  may  very  readily  be  mistaken  for  the  vertex.  At 
this  stage  the  diagnosis  may  be  facilitated  by  abdominal  palpation 
in  the  way  suggested  by  Hecker.  If  the  face  is  presenting  at  the 
brim,  palpation  will  enable  us  to  distinguish  a  hard,  firm,  and 
rounded  body,  immediately  above  the  pubis,  which  is  the  forehead 
and  sinciput ;  on  the  other  side  will  be  felt  an  indistinct  soft  sub- 
stance, corresponding  to  the  thorax  and  neck.  When  labor  is  ad- 
vanced, and  the  head  has  somewhat  descended,  or  when  the 
membranes  are  ruptured,  we  should  be  able  to  make  out  the  nature 
of  the  presentation  with  certainty.  The  diagnostic  marks  to  be 
relied  on  are  the  edges  of  the  orbits,  the  prominence  of  the  nose,  the 
nostrils  (their  orifices  showing  to  which  part  of  the  pelvis  the  chin 
is  turned),  and  the  cavity  of  the  mouth,  with  the  alveolar  ridges. 
If  these  be  made  out  satisfactorily,  no  mistake  should  occur.  The 
most  difficult  cases  are  those  in  which  the  face  has  been  a  consider- 
able time  in  the  pelvis.  Under  such  circumstances  the  cheeks  be- 
come greatly  swollen  and  pressed  together,  so  as  to  resemble  the 
nates.  The  nose  might  then  be  mistaken  for  the  genital  organs,  and 
the  mouth  for  the  anus.  The  orbits,  however,  and  the  alveolar 
ridges,  resemble  nothing  in  the  breech,  and  should  be  sufficient  to 
prevent  error.  Considerable  care  should  be  taken  not  to  examine 
too  frequently  and  roughly,  otherwise  serious  injury  to  the  delicate 
structures  of  the  face  might  be  inflicted.  When  once  the  presenta- 
tion has  been  satisfactorily  diagnosed,  examinations  should  be  made 
as  seldom  as  possible,  and  only  to  assure  ourselves  that  the  case  is 
progressing  satisfactorily. 

Mechanism. — If  we  regard  face  presentations,  as  we  are  fully  justi- 
fied in  doing,  as  being  generally  produced  by  the  extension  of  the 
occiput  in  what  were  originally  vertex  presentations,  we  can  readily 
understand  that  the  position  of  the  face  in  relation  to  the  pelvis  must 
correspond  to  that  of  the  vertex.  This  is,  in  fact,  what  is  found  to 
be  the  case,  the  forehead  occupying  the  position  in  which  the  occiput 
would  have  been  placed  had  extension  not  occurred. 

The  Positions  of  the  Face  correspond  to  those  of  the  Vertex. — The 
face,  then,  like  the  head,  may  be  placed  with  its  long  diameter 
corresponding  to  almost  any  of  the  diameters  of  the  brim,  but  most 
generally  it  lies  either  in  the  transverse  diameter,  or  between  this 


300  LABOR. 

and  the  oblique,  while,  as  it  descends  in  the  pelvis,  it  more  .generally 
occupies  one  or  other  of  the  oblique  diameters.  It  is  common  in 
obstetric  works  to  describe  two  principal  varieties  of  face  presenta- 
tion, viz.,  the  right  and  left  mento-iliac,  according  as  the  chin  is 
turned  to  one  or  other  side  of  the  pelvis.  It  is  better,  however,  to 
classify  the  positions  in  accordance  with  the  part  of  the  pelvis  to 
which  the  chin  points.  We  may,  therefore,  describe  four  positions 
of  the  face,  each  being  analogous  to  one  of  the  ordinary  vertex 
presentations,  of  which  it  is  the  transformation. 

First  position. — The  chin  points  to  the  right  sacro-iliac  synchon- 
drosis,  the  forehead  to  the  left  foramen  ovale,  and  the  long  diameter 
of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis.  This 
corresponds  to  the  first  position  of  the  vertex,  and,  as  in  that,  the 
back  of  the  child  lies  to  the  left  side  of  the  mother. 

Second  position. — The  chin  points  to  the  left  sacro-iliac  synchon- 
drosis,  the  forehead  to  the  right  foramen  ovale,  and  the  long  diameter 
of  the  face  lies  in  the  left  oblique  diameter  of  the  pelvis.  This  is 
the  conversion  of  the  second  vertex  position. 

FIG.  107. 


Second  Position  in  Face  Presentations. 


Third  position. — The  forehead  points  to  the  right  sacro-iliac  syn- 
chondrosis,  the  chin  to  the  left  foramen  ovale,  and  the  long  diameter 
of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis.  This  is 
the  conversion  of  the  third  vertex  position. 

Fourth  position. — The  forehead  points  to  the  left  sacro-iliac  syn- 
chondrosis,  the  chin  to  the  right  foramen  ovale,  and  the  long  dia- 
meter of  the  face  lies  in  the  left  oblique  diameter  of  the  pelvis.  This 
is  the  conversion  of  the  fourth  vertex  position. 


PRESENTATIONS    OF    THE    FACE.  301 

Relative  Frequency  of  these  Positions.  —  The  relative  frequency  of 
these  presentations  is  not  yet  positively  ascertained.  It  is  certain 
that  there  is  not  the  preponderance  of  first  facial  that  there  is  of  first 
vertex  positions,  arid  this  may,  no  doubt,  be  explained  by  the  suppo- 
sition that  an  unusual  vertex  position  may  of  itself  facilitate  the 
transformation  into  a  face  presentation.  Winckel  concludes  that, 
cseteris  paribus,  a  face  presentation  is  more  readily  produced  when 
the  back  of  the  child  lies  to  the  right  than  when  it  lies  to  the  left 
side  of  the  mother;  the  reason  for  this  being  probably  the  frequency 
of  right  lateral  obliquity  of  the  uterus.  We  shall  presently  see  that, 
with  very  rare  exceptions,  it  is  absolutely  essential  that  the  chin 
should  rotate  forwards  under  the  pubis  before  delivery  can  be 
accomplished;  and,  therefore,  we  may  regard  the  third  and  fourth 
face  positions,  in  which  the  chin  from  the  first  points  anteriorly,  as 
more  favorable  than  the  first  and  second. 

Mechanism.  —  The  mechanism  of  delivery  in  face  is  practically  the 
same  as  in  vertex  presentations;  and  we  shall  have  no  difficulty  in 
understanding  it  if  we  bear  in  rnind  that  in  face  cases  the  forehead 
takes  the  place,  and  represents,  the  occiput  in  vertex  presentations. 
For  the  purpose  of  description  we  will  take  the  first  position  of  the 
face  — 

Description  of  Delivery  in  the  First  Position  of  the  Face.  —  1.  The 
first  step  consists  in  the  extension  of  the  head,  which  is  effected  bv 
the  uterine  contractions  as  soon  as  the  membranes  are  ruptured.  By 
this  the  occiput  is  still  more  completely  pressed  back  on  the  nape  of 
the  neck,  and  the  fronto-m^ntal,  rather  than  the  mento-bregmatic, 
diameter  is  placed  in  relation  to  the  pelvic  brim.  This  corresponds 
to  the  stage  of  flexion  in  vertex  presentations. 

The  chin  descends  below  the  forehead,  from  precisely  the  same 
cause  as  the  occiput  in  vertex  presentations.  On  account  of  the  ex- 
tended position  of  the  head  the  presenting  face  is  divided  into  por- 
tions of  unequal  length  in  relation  to  the  vertebral  column,  through 
which  the  force  is  applied,  the  longer  lever  arm  being  towards  the 
forehead.  The  resistance  is,  therefore,  greatest  towards  the  fore- 
head, which  remains  behind  while  the  chin  descends. 

2.  Descent.  —  As  the  pains  continue,  the  head  (the  chin  being  still 
in  advance)  is  propelled  through  the  pelvis.     It  is  generally  said  that 
the  face  cannot  descend,  like  the  occiput,  down  to  the  floor  of  the 
pelvis,  its  descent  being  limited  by  the  length  of  the  neck.     There  is 
here,  however,  an  obvious  misapprehension.      The  neck,  from  the 
chin  to  the  sternum,  when  the  head  is  forcibly  extended,  measures 
from  3J  to  4  inches,  a  length  that  is  more  than  sufficient  to  admit  of 
the  face  descending  to  the  lower  pelvic  strait.      As  a  matter  of  fact 
the  chin  is  frequently  observed  in  mento-posterior  positions  to  de- 
scend so  far  that  it  is  apparently  endeavoring  to  pass  the  perineum 
before  rotation  occurs.     At  the  brim  the  two  sides  of  the  face  are  on 
a  level,  but,  as  labor  advances,  the  right  cheek  descends  somewhat, 
the  caput  succedaneum  forms  on  the  malar  bone,  and,  if  a  secondary 
caput  succedaneum  form,  on  the  cheek. 

3.  Rotation  is  by  far  the  most  important  point  in  the  mechanism 


U          H  If  01-  ATI-l 

l-K\  ElCl/Uvi  c  UKUl£CK 


302 


LABOR. 


of  face  presentations ;  for  unless  it  occurs,  delivery,  with  a  full-sized 
head  and  an  average  pelvis,  is  practically  impossible.     There  are,  no 


FIG.  108. 


Rotation  Forwards  of  Chin. 


doubt,  exceptions  to  this  rule,  which  must  be  separately  considered, 
but  it  is  certain  that  the  absence  of  rotation  is  always  a  grave  and 


FIG.  109. 


Passage  of  the  Head  through  the  External  Parts  in  Face  Presentation. 

formidable  complication  of  face  presentation.     Fortunately  it  is  only 
very  rarely  that  it  is  not  effected.     The  mechanical  causes  are  pre- 


PKESENTATIONS    OF    THE    FACE.  803 

cisely  those  which  produce  rotation  of  the  occiput  forwards  in  vertex 
presentations.  As  it  is  accomplished,  the  chin  passes  under  the  arch 
of  the  pubis,  and  the  occiput  rotates  into  the  hollow  of  the  sacrum 
(Fig.  108) ;  and  then  commences- — 

4.  Flexion,  a  movement  which  corresponds  to  extension  in  vertex 
cases.     The  chin  passes  as  far  as  it  can  under  the  pubic  arch,  and 
there  becomes  fixed.      The  uterine  force  is  now  expended  on  the  oc- 
cupit,  which  revolves,  as  it  were,  on  its  transverse  axis  (Fig  109), 
the  under  surface  of  the  chin  resting  on  the  pubis  as  a  fixed  point. 
This  movement  goes  on  until,  at  last,  the  face  and  occiput  sweep  over 
the  distended  perineum. 

5.  External  Rotation  is  precisely  similar  to  that  which  takes  place 
in  head  presentations,  and,  like  it,  depends  on  the  movements  im- 
parted to  the  shoulders. 

FIG.  110. 


Illustrating  the  Position  of  the  Head  when  Forward  Rotation  of  the  Chin 
does  not  take  place. 

Such  is  the  natural  course  of  delivery  in  the  vast  majority  of 
cases ;  but,  in  order  fully  to  understand  the  subject,  it  is  necessary 
to  study  those  rare  cases  in  which  the  chin  points  backwards,  and 
forward  rotation  does  not  occur.  These  may  be  taken  to  correspond 
to  the  occipito-po^terior  positions,  in  which  the  face  is  born  looking 
to  the  pubes ;  but,  unlike  them,  it  is  only  very  exceptionally  that 
delivery  can  be  naturally  completed.  The  reason  of  this  is  obvious, 
for  the  occiput  gets  jammed  behind  the' pubis,  and  there  is  no  space 
for  the  fronto-mental  diameter  to  pass  the  antero-posterior  diameter 
of  the  outlet  (Fig.  110).  Cases  are  indeed  recorded,  in  which  delivery 
has  been  effected  with  the  chin  looking  posteriorly ;  but  there  is 
every  reason  to  believe  that  this  can  only  happen  when  the  head  is 
either  unusually  small,  or  the  pelvis  unusually  large.  In  such  cases 
the  forehead  is  pressed  down  until  a  portion  appears  at  the  ostium 


304  LABOR. 

vaginae,  when  it  becomes  firmly  fixed  behind  the  pubis,  and  the  chin, 
after  many  efforts,  slips  over  the  perineum.  When  this  is  effected 
flexion  occurs,  and  the  occiput  is  expelled  without  difficulty.  The 
forehead  is  probably  always  on  a  lower  level  than  the  chin. 

Dr.  Hicks'  has  published  a  paper,  in  which  he  attempts  to  show 
that  this  termination  of  face  presentations  is  not  so  rare  as  is  gene- 
rally supposed,  and  he  gives  a  single  instance  in  which  he  effected 
delivery  with  the  forceps;  but  he  practically  admits  that  special 
conditions  are  necessary,  such  as  the  "  antero-posterior  diameter  of 
the  outlet  particularly  ample,"  and  a  diminished  size  of  the  head. 
When  delivery  is  effected  it  is  probable,  as  Cazeaux  has  pointed  out, 
that  the  face  lies  in  the  oblique  diameter  of  the  outlet,  and  that  the 
chin  depresses  the  soft  structures  at  the  side  of  the  sacro-ischiatic 
notch,  which  yield  to  the  extent  of  a  quarter  of  an  inch  or  more, 
and  thereby  permit  the  passage  of  the  occipito-mental  diameter  of 
the  head.  It  must,  however,  be  borne  well  in  mind,  that  spontaneous 
delivery  in  mento-posterior  positions  is  the  rare  exception,  and  that, 
supposing  rotation  does  not  occur — and  it  often  does  so  at  the  last 
moment — artificial  aid  in  one  form  or  another  will  be  almost  certainly 
required. 

Prognosis  of  Face  Presentations. — As  regards  the  mother,  in  the 
great  majority  of  cases  the  prognosis  is  favorable,  but  the  labor  is 
apt  to  be  prolonged,  and  she  is,  therefore,  more  exposed  to  the  risks 
attending  tedious  delivery.  As  regards  the  child,  the  prognosis  is 
much  more  unfavorable  than  in  vertex  presentations.  Even  when 
the  anterior  rotation  of  the  chin  takes  place  in  the  natural  way,  it  is 
estimated  that  1  out  of  10  children  is  stillborn;  while  if  not,  the 
death  of  the  child  is  almost  certain.  This  increased  infantile  mor- 
tality is  evidently  due  to  the  serious  amount  of  pressure  to  which 
the  child  is  subjected,  and  probably  depends  in  many  cases  on  cere- 
bral congestion,  produced  by  pressure  on  the  jugular  veins,  as  the 
neck  lies  in  the  pelvic  cavity.  Even  when  the  child  is  born  alive, 
the  face  is  always  greatly  swollen  and  disfigured.  In  some  cases  the 
deformity  produced  in  this  wayis  excessive,  and  the  features  are 
often  scarcely  recognizable.  This  disfiguration  passes  away  in  a  few 
days;  but  the  practitioner  should  be  aware  of  the  probability  of  its 
occurrence,  and  should  warn  the  friends,  or  they  might  be  unneces- 
sarily alarmed,  and  possibly  might  lay  the  blame  on  him. 

Treatment — After  what  has  been  said  as  to  the  mechanism  of  de- 
livery in  face  presentation,  it  is  obvious  that  the  proper  course  is  to 
leave  the  case  alone,  in  the  expectation  of  the  natural  efforts  being 
sufficient  to  complete  delivery.  Fortunately,  in  the  large  majority 
of  cases,  this  course  is  attended  by  a  successful  result. 

The  older  accoucheurs,  as  has  been  stated,  thought  active  inter- 
ference absolutely  essential,  and  recommended  either  podalic  version, 
or  the  attempt  to  convert  the  case  into  a  vertex  presentation,  by  in- 
serting the  hand  and  bringing  down  the  occiput.  The  latter  plan 
was  recommended  by  Baudelocque,  and  is  even  yet  followed  by  some 

1  Obst.  Trans.,  vol.  vii. 


PRESENTATIONS    OF    THE    FACE.  305 

accoucheurs.  Thus  Dr.  Hodge1  advises  it  in  all  cases  in  which  face 
presentation  is  detected  at  the  brim  ;  but  although  it  might  not  have 
been  attended  with  evil  consequences  in  his  experienced  hands,  it  is 
certainly  altogether  unnecessary,  and  would  infallibly  lead  to  most 
serious  results  if  generally  adopted.  It  may,  however,  be  allowable 
in  certain  cases  in  which  the  face  remains  above  the  brim,  and  re- 
fuses to  descend  into  the  pelvic  cavity.  Even  then  it  is  questionable 
whether  podalic  version  should  not  be  preferred,  as  being  easier  of 
performance,  giving,  when  once  effected,  a  much  more  complete 
control  over  delivery,  and  being  less  painful  to  the  mother.  Ver- 
sion is  certainly  preferable  to  the  application  of  the  forceps,  which 
are  introduced  with  difficulty  in  so  high  a  position  of  the  face,  and 
do  not  take  a  secure  hold. 

When  once  the  face  has  descended  into  the  pelvis,  difficulties  may 
arise  from  two  chief  causes ;  uterine  inertia,  and  non-rotation  for- 
wards of  the  chin. 

The  treatment  of  the  former  class  must  be  based  on  precisely  the 
same  general  principles  as  in  dealing  with  protracted  labor  in  vertex 
presentations.  The  forceps  may  be  applied  with  advantage,  bearing 
in  mind  the  necessity  of  getting  the  chin  under  the  pubis,  and,  when 
this  has  been  effected,  of  directing  the  traction  forwards,  so  as  to 
make  the  occupit  slowly  and  gradually  distend  and  sweep  over  the 
perineum. 

Difficulties  arising  from  -Non-rotation  of  Chin  Forwards. — The 
second  class  of  difficult  face  cases  are  much  more  important,  and  may 
try  the  resources  of  the  accoucheur  to  the  utmost.  Our  first  en- 
deavor must  be,  if  possible,  to  secure  the  anterior  rotation  of  the  chin. 
For  this  purpose  various  manoeuvres  are  recommended.  By  some, 
we  are  advised  to  introduce  the  finger  cautiously  into  the  mouth  of 
the  child,  and  draw  the  chin  forwards  during  a  pain ;  by  others,  to 
pass  the  finger  up  behind  the  occiput  and  press  it  backwards  during 
the  pain.  Schroeder  points  out  that  the  difficulty  often  depends  on 
the  fact  of  the  head  not  being  sufficiently  extended,  so  that  the  chin 
is  not  on  a  lower  level  than  the  forehead  ;  and  that  rotation  is  best 
promoted  by  pressing  the  forehead  upwards  with  the  finger  during 
a  pain,  so  as  to  cause  the  chin  to  descend.  Penrose2  believes  that 
non-rotation  is  generally  caused  by  the  want  of  a  point  cfappui 
below,  on  account  of  the  face  being  able  to  descend  to  the  floor  of 
the  pelvis,  and  that,  if  this  is  supplied,  rotation  will  take  place. 
In  such  cases  he  applies  the  hand,  or  the  blade  of  the  forceps,  so 
as  to  press  on  the  posterior  cheek.  By  this  means  the  necessary 
"  point  d'appui  "  is  given  ;  and  he  relates  several  interesting  cases  in 
which  this  simple  manoeuvre  was  effectual  in  rapidly  terminating 
a  previously  lengthy  labor.  Any,  or  all,  of  these  plans  may  be 
tried.  We  must  bear  in  mind,  in  using  them,  that  rotation  is  often 
delayed  until  the  face  is  quite  at  the  lower  pelvic  strait,  so  that  we 
need  not  too  soon  despair  of  its  occurring.  If,  however,  in  spite 

1  System  of  Obstetrics,  p.  335. 

2  Amer.  Supplement  to  Obst   Journ.,  April,  1876. 


306  LABOR. 

of  these  manoeuvres,  it  do  not  take  place,  what  is  to  be  done  ? 
If,  the  head  be  not  too  low  down  in  the  pelvis  to  admit  of  version, 
that  would  be  the  simplest  and  most  effectual  plan.  I  have  suc- 
ceeded in  delivering  in  this  way,  when  all  attempts  at  producing 
rotation  had  failed;  but  generally  the  face  will  be  too  decidedly 
engaged  to  render  it  possible.  An  attempt  might  be  made  to  bring 
down  the  occiput  by  the  vectis,  or  by  a  fillet ;  but,  if  the  face  be 
in  the  pelvic  cavity,  it  is  hardly  possible  for  this  plan  to  succeed. 
An  endeavor  may  be  made  to  produce  rotation  by  the  forceps ; 
but  it  should  be  remembered  that  rotation  of  the  face  mechanically 
in  this  way  is  very  difficult,  and  much  more  likely  to  be  attended 
with  fatal  consequences  to  the  child,  than  when  it  is  effected  by  the 
natural  efforts.  In  using  forceps  for  this  purpose,  the  second  or. 
pelvic  curve  is  likely  to  prove  injurious,  and  a  short  straight  instru- 
ment is  to  be  preferred.  If  rotation  be  found  to  be  impossible,  an 
endeavor  may  be  made  to  draw  the  face  downwards,  so  as  to  get  the 
chin  over  the  perineum,  and  deliver  in  the  mento-posterior  position ; 
but,  unless  the  child  be  small,  or  the  pelvis  very  capacious,  the  at- 
tempt is  unlikely  to  succeed.  Finally,  if  all  these  means  fail,  there 
is  no  resource  left  but  lessening  the  size  of  the  head  by  craniotorny, 
a  dernier  ressort  which,  fortunately,  is  very  rarely  required. 

Brow  Presentations. — It  sometimes  happens  that  the  head  is  par- 
tially extended,  so  as  bring  the  os  frontis  into  the  brirn  of  the  pelvis, 
and  form  what  is  described  as  a  "  brow  presentation."  Should  the 
head  descend  in  this  manner,  the  difficulties,  although  not  insupera- 
ble, are  apt  to  be  very  great,  from  the  fact  that  the  long  cervico- 
frontal  diameter  of  the  head  is  engaged  in  the  pelvic  cavity.  The 
diagnosis  is  not  difficult,  for  the  os  frontis  will  he  detected  by  its 
rounded  surface ;  while  the  anterior  fontanelle  is  within  reach  in 
one  direction,  the  orbit,  and  root  of  the  nose,  in  another. 

Spontaneously  converted  into  either  face  or  Vertex  Presentations. — 
Fortunately,  in  the  large  majority  of  cases  brow  presentations  are 
spontaneously  converted  into  either  vertex  or  face  presentations, 
according  as  flexion  or  extension  of  the  head  occurs  ;  and  these  must 
be  regarded  as  the  desirable  terminations  and  the  ones  to  be  favored. 
For  this  purpose  upward  pressure  must  be  made  on  one  or  other  ex- 
tremity of  the  presenting  part  during  a  pain,  so  as  to  favor  flexion, 
or  extension ;  or,  if  the  parts  be  sufficiently  dilated,  an  attempt  may 
be  made  to  pass  the  hand  over  the  occiput  and  draw  it  down,  thus 
performing  cephalic  version.  The  latter  is  the  plan  recommended 
by  Hodge,  who  describes  the  operation  as  easy.  It  is  questionable, 
however,  if  a  well-marked  brow  presentation  be  distinctly  made  out 
while  the  head  is  still  at  the  brim,  whether  podalic  version  would 
not  be  the  easiest  and  best  operation.  If  the  forehead  have  descended 
too  low  for  this,  and  if  the  endeavor  to  convert  it  into  either  a  face 
or  vertex  presentation  fail,  the  forceps  will,  probably,  be  required. 
In  such  cases  the  face  generally  turns  towards  the  pubes,  the  supe- 
rior maxilla  becomes  fixed  behind  the  pubic  arch,  and  the  occiput 
sweeps  over  the  perineum.  Very  great  difficulty  is  likely  to  be  ex- 
perienced, and  if  conversion  into  either  a  vertex  or  face  presentation 
cannot  be  effected,  craniotomy  is  not  unlikely  to  be  required. 


DIFFICULT    OCCIPITO-POSTERIOR    POSITIONS.  307 


CHAPTER  VII. 

DIFFICULT    OCCIPITO-POSTERIOR   POSITIONS. 

A  FEW  words  may  be  said  in  this  place  as  to  the  management  of 
occipito-posterior  positions  of  the  head,  especially  of  those  in  which 
forward  rotation  of  the  occiput  does  not  take  place.  It  has  already 
been  pointed  out  that,  in  the  large  majority  of  these  cases,  the  occiput 
rotates  forward  without  any  particular  difficulty,  and  the  labor  termi- 
nates in  the  usual  way,  with  the  occiput  emerging  under  the  arch  of 
the  pubis. 

Rotation  Forwards  of  the  Occiput. — In  a  certain  number  of  cases 
such  rotation  does  not  occur,  and  difficulty  and  delay  are  apt  to  fol- 
low. The  proportion  of  cases  in  which  face  to  pubis  terminations  of 
occipito-posterior  positions  occurs  has  been  variously  estimated,  and 
they  are  certainly  more  common  than  most  of  our  text-books  lead 
us  to  expect.  Dr.  Uvedale  West,1  who  studied  the  subject  with  great 
care,  found  that  labor  ended  in  this  way  in  79  out  of  2585  births,  all 
these  deliveries  being  exceptionally  difficult. 

Caiises  of  Face  to  Pubis  Delivery. — He  believed  that  forward  rota- 
tion of  the  head  is  prevented  by  the  absence  of  flexion  of  the  chin 
on  the  sternum,  so  that  the  long  occipito-frontal,  instead  of  the  short 
sub-occipito-bregrnatic,  diameter  of  the  head  is  brought  into  contact 
with  the  pelvic  diameter ;  hence  the  occiput  is  no  longer  the  lowest 
point,  and  is  not  subjected  to  the  action  of  those  causes  which  pro- 
duce forward  rotation.  Dr.  Macdonald,  who  has  written  a  thoughtful 
paper  on  the  subject,2  believes  that  the  non-rotation  forward  of  the 
occiput  is  chiefly  due  to  the  large  size  of  the  head,  in  consequence 
of  which  "  the  forehead  gets  so  wedged  into  the  pelvis  anteriorly 
that  its  tendency  to  slacken  and  rotate  forward  does  not  come  into 
play."  Dr.  West's  explanation,  which  has  an  important  bearing  on 
the  management  of  these  cases,  seems  to  explain  most  correctly  the 
non-occurrence  of  the  natural  rotation. 

The  important  question  for  us  to  decide  is,  how  can  we  best  assist 
in  the  management  of  cases  of  this  kind  when  difficulties  arise,  and 
labor  is  seriously  retarded? 

Mode  of  Treatment. — Dr.  West,  insisting  strongly  on  the  necessity 
of  complete  flexion  of  the  chin  on  the  sternum,  advises  that  this 
should  be  favored  by  upward  pressure  on  the  frontal  bone,  with  the 
view  of  causing  the  chin  to  approach  the  sternum,  and  the  occiput 
to  descend,  and  thus  to  come  within  the  action  of  the  agencies  which 
favor  rotation.  Supposing  the  pains  to  be  strong,  and  the  fontanelle 
to  be  readily  within  reach,  we  may,  in  this  way,  very  possibly  favor 

1  Cranial  Presentations,  p.  33.  2  Edin.  Med.  Jour.,  Oct.. 1874. 


308  LABOR. 

the  descent  of  the  occiput;  and  without  injuring  the  mother,  or  in- 
creasing the  difficulties  of  the  case  in  the  event  of  the  manoeuvre 
failing.  The  beneficial  effects  of  this  simple  expedient  are  some- 
times very  remarkable.  In  two  cases  in  which  I  recently  adopted 
it,  labor,  previously  delayed  for  a  length  of  time  without  any  appa- 
rent progress,  although  the  pains  were  strong  and  effective,  was  in 
each  instance  rapidly  finished  almost  immediately  after  the  upward 
pressure  was  applied.  The  rotation  of  the  face  backwards  may  at 
the  same  time  be  favored  by  pressure  on  the  pubic  side  of  the  fore- 
head during  the  pains. 

Traction  on  the  Occiput. — Others  have  advised  that  the  descent  of 
the  occiput  should  be  promoted  by  downward  traction,  applied  by  the 
vectis  or  fillet.  The  latter  is  the  plan  specially  advocated  by  Hodge;1 
and  the  fillet  certainly  finds  one  of  its  most  useful  applications  in 
cases  of  this  kind,  as  being  simpler  of  application,  and  probably 
more  effective,  than  the  vectis. 

Over-active  Endeavors  at  Assistance  should  he  avoided. — Although 
any  of  these  methods  may  be  adopted,  a  word  of  caution  is  necessary 
against  prolonged  and  over-active  endeavors  at  producing  flexion  and 
rotation  when  that  seems  delayed.  All  who  have  watched  such  cases 
must  have  observed  that  rotation  often  occurs  spontaneously  at  a  very 
advanced  period  of  labor,  long  after  the  head  has  been  pressed  down 
for  a  considerable  time  to  the  very  outlet  of  the  pelvis,  and  when  it 
seems  to  have  been  making  fruitless  endeavors  to  emerge;  so  that  a 
little  patience  will  often  be  sufficient  to  overcome  the  difficulty. 
[Where  the  hand  of  the  accoucheur  is  small,  and  vaginal  outlet  suffi- 
ciently large,  it  may  be  introduced,  and  the  occiput  brought  obliquely 
downward  and  forward  by  slow  degrees,  in  the  intervals  between  two 
or  three  pains,  until  the  changed  position  is  secured  by  uterine  con- 
traction. "We  have  executed  this  movement  with  great  ease,  by 
employing  the  left  hand,  even  in  primiparae.  A  large  hand  is  entirely 
unsuitable. — ED.] 

When  necessary  the  Forceps  may  he  Used. — In  the  event  of  assist- 
ance being  absolutely  required,  there  is  no  reason  why  the  forceps 
should  not  be  used.  The  instrument  is  not  more  difficult  to  apply 
than  under  ordinary  circumstances,  nor,  as  a  rule,  is  much  more  trac- 
tion necessary.  Dr.  Macdonald,  indeed,  in  the  paper  already  alluded 
to,  maintains  that  in  persistent  occipito-posterior  positions  there  is 
almost  always  a  want  of  proportion  between  the  head  and  the  pelvis, 
and  that,  therefore,  the  forceps  will  be  generally  required,  and  he 
prefers  them  to  any  artificial  attempts  at  rectification.  Some  pecu- 
liarities in  the  mode  of  delivery  are  necessar}'  to  bear  in  mind.  In 
most  works  it  is  taught,  that  the  operator  should  pay  special  atten- 
tion to  the  rotation  of  the  head,  and  should  endeavor  to  impart  this 
movement  by  turning  the  occiput  forward  during  extraction.  Thus 
Tyler  Smith  says,  "  In  delivery  with  the  forceps  in  occipito-posterior 
presentations,  the  head  should  be  slowly  rotated  during  the  process 
of  extraction  so  as  to  bring  the  vertex  towards  the  pubic  arch,  and 

1  System  of  Obstetrics,  p.  308. 


PRESENTATIONS  OF  SHOULDER, ETC.  309 

thus  convert  them  into  occipito-anterior  presentations."  The  danger 
accompanying  any  forcible  attempt  at  artificial  rotation  will,  how- 
ever, be  evident  on  slight  consideration.  It  is  true  that  in  nianv 
cases,  when  simple  traction  is  applied,  the  occiput  will,  of  itself,  ro- 
tate forwards,  carrying  the  instrument  with  it.  But  that  is  a  very 
different  thing  from  forcibly  twisting  round  the  head  with  the  blades 
of  the  forceps,  without  any  assurance  that  the  body  of  the  child  will 
follow  the  movement.  It  is  impossible  to  conceive  that  such  violent 
interference  should  not  be  attended  with  serious  risk  of  injury  to  the 
neck  of  the  child.  If  rotation  do  not  occur,  the  fair  inference  is, 
that  the  head  is  so  placed  as  to  render  delivery  with  the  face  to  the 
pubis  the  best  termination,  and  no  endeavor  should  be  made  to  pre- 
vent it.  This  rule  of  leaving  the  rotation  entirely  to  nature,  and 
using  traction  only,  has  received  the  approval  of  Barnes  and  most 
modern  authorities,  and  is  the  one  which  recommends  itself  as  the 
most  scientific  and  reasonable. 

Objection  to  Curved  Instruments  in  such  Cases. — These  are  cases  in 
which  the  pelvic  curve  of  the  forceps  is  of  doubtful  utility.  A\rhen 
applied  in  the  usual  way  the  convexity  of  the  blades  points  back- 
wards. If  rotation  accompany  extraction,  the  blades  necessarily 
follow  the  movement  of  the  head,  and  their  convex  edges  will  turn 
forwards.  It  certainly  seems  probable  that  such  a  movement  would 
subject  the  maternal  soft  parts  to  considerable  risk.  I  have,  how- 
ever, more  than  once  seen  such  rotation  of  the  instrument  happen 
without  any  apparent  bad  'result ;  but  the  dangers  are  obvious. 
Hence  it  would  be  a  wise  precaution,  either  to  use  a  pair  of  straight 
forceps  for  this  particular  operation,  or  to  remove  the  blades  and 
leave  the  case  to  be  terminated  by  the  natural  powers,  when  the  head 
is  at  the  lower  strait,  and  rotation  seems  about  to  occur.  When 
there  is  no  rotation,  more  than  usual  care  should  be  taken  with  the 
perineum,  which  is  necessarily  much  stretched  by  the  rounded  occiput. 
Indeed  the  risk  to  the  perineum  is  very  considerable,  and,  even  with 
the  greatest  care,  it  may  be  impossible  to  avoid  laceration. 

Bearing  these  precautions  in  mind,  delivery  with  the  forceps  in 
occipito-posterior  positions  offers  no  special  difficulties  or  dangers. 


CHAPTER  VIII. 

PRESENTATIONS  OF  THE  SHOULDER,  ARM,  OR  TRUNK — COMPLEX 
PRESENTATIONS — PROLAPSE  OF  THE  FUNIS. 

IN  the  presentations  already  considered  the  long  diameter  of  the 
foetus  corresponded  with  that  of  the  uterine  cavity,  and,  in  all  of 
them,  the  birth  of  the  child  by  the  maternal  efforts  was  the  general 
and  normal  termination  of  labor.  We  have  now  to  discuss  those 


310  LABOR. 

important  cases  in  which  the  long  diameter  of  the  foetus  and  uterus 
do  not  correspond,  but  in  which  the  long  foetal  diameter  lies  ob- 
liquely across  the  uterine  cavity.  In  the  large  majority  of  these  it  is 
either  the  shoulder,  or  some  part  of  the  upper  extremity,  that  presents; 
for  it  is  an  admitted  fact  that  although  other  parts  of  the  body,  such 
as  the  back,  or  abdomen,  may,  in  exceptional  cases,  lie  over  the  os 
at  an  early  period  of  labor,  yet,  as  labor  progresses,  such  presenta- 
tions are  almost  always  converted  into  those  of  the  upper  extremity. 

For  all  practical  purposes  we  may  confine  ourselves  to  a  considera- 
tion of  shoulder  presentations;  the  further  subdivision  of  these  into 
elbow  or  hand  presentations  being  no  more  necessary  than  the  division 
of  pelvic  presentations  into  breech,  knee,  and  footling  cases,  since 
the  mechanism  and  management  are  identical,  whatever  part  of  the 
upper  extremity  presents. 

Delivery  by  the  Natural  Powers  is  quite  Exceptional. — There  is  this 
great  distinction  between  the  presentations  we  are  now  considering 
and  those  already  treated  of,  that,  on  account  of  the  relations  of  the 
fcetus  to  the  pelvis,  delivery  by  the  natural  powers  is  impossible, 
except  under  special  and  very  unusual  circumstances  that  can  never 
be  relied  upon.  Intervention  on  the  part  of  the  accoucheur  is,  there- 
fore, absolutely  essential,  and  the  safety  of  both  the  mother  and 
child  depends  upon  the  early  detection  of  the  abnormal  position  of 
the  fcetus ;  for  the  necessary  treatment,  which  is  comparatively  easy 
and  safe  before  labor  has  been  long  in  progress,  becomes  most  diffi- 
cult and  hazardous  if  there  have  been  much  delay. 

Position  of  the  Fcetus. — Presentations  of  the  upper  extremity  or 
trunk  are  often  spoken  of  as  "transverse  presentations"  or  "cross 
births-"  but  both  of  these  terms  are  misleading,  as  they  imply  that 
the  foetus  is  placed  transversely  in  the  uterine  cavity,  or  that  it  lies 
directly  across  the  pelvic  brim.  As  matter  of  fact,  this  is  never  the 
case,  for  the  child  lies  obliquely  in  the  uterus,  not  indeed  in  its 
long  axis,  but  in  one  intermediate  between  its  long  and  transverse 
diameters. 

Divided  into  Dorso-anterior  and  Dorso-posterior  Positions. — Two 
great  divisions  of  shoulder  presentations  are  recognized ;  the  one  in 
which  the  back  of  the  child  looks  to  the  abdomen  of  the  mother 
(Fig.  Ill),  and  the  other  in  which  the  back  of  the  child  is  turned 
towards  the  spine  of  the  mother  (Fig.  112).  Each  of  these  is  sub- 
divided into  two  subsidiary  classes,  according  as  the  head  of  the 
child  is  placed  in  the  right  or  left  iliac  fossa.  Thus  in  dorso-anterior 
positions,  if  the  head  lie  in  the  left  iliac  fossa,  the  right  shoulder  of 
the  child  presents ;  if  in  the  right  iliac  fossa,  the  left.  So  in  dorso- 
posterior  positions,  if  the  head  lie  in  the  left  iliac  fossa,  the  left 
shoulder  present ;  if  in  the  right,  the  right.  Of  the  two  classes  the 
dorso-anterior  positions  are  more  common,  in  the  proportion,  it  is 
said,  of  two  to  one. 

Causes. — The  causes  of  shoulder  presentations  are  not  well  known. 
Amongst  those  most  commonly  mentioned  are  prematurity  of  the 
fcetus,  and  excess  of  liquor  amnii ;  either  of  these,  by  increasing  the 
mobility  of  the  fcetus  in  utero,  would  probably  have  considerable 


PRESENTATIONS    OF    SHOULDER,    ETC. 


311 


influence.     The  fact  that  it  occurs  much  more  frequently  amongst 
premature  births  has  long  been  recognized.     Undue  obliquity  of  the 


FIG.  111. 


Dorso-anterior  Presentation  of  the  Arm. 


uterus  has  probably  some  influence,  since  the  early  pains  might 
cause  the  presenting  part  to  hitch  against  the  pelvic  brim,  and  the 


FIG.  H2. 


Dorso-posterior  Presentations  of  the  Arm. 


shoulder  to  descend.  An  unusually  low  attachment  of  the  placenta 
to  the  inferior  segment  of  the  uterine  cavity  has  been  mentioned  as 
a  predisposing  cause.  In  consequence  of  this  the  head  does  not  lie 


312  LABOR. 

so  readily  in  the  lower  uterine  segment,  and  is  apt  to  slip  up  into 
one  of  the  iliac  fossae.  This  is  supposed  to  explain  the  frequency  of 
arm  presentation  in  cases  of  partial  or  complete  placenta  prajvia. 
Danyou  and  Wigand  believe  that  shoulder  presentations  are  favored 
by  irregularity  in  the  shape  of  the  uterine  cavity,  especially  a  rela- 
tive increase  in  its  transverse  diameter.  This  theory  has  been  gene- 
rally discredited  by  writers,  and  it  is  certainly  not  susceptible  of 
proof;  but  it  seems  far  from  unlikely  that  some  peculiarity  of  shape 
may  exist,  not  capable  of  recognition,  but  sufficient  to  influence  the 
position  of  the  foetus.  How  otherwise  are  we  to  explain  those  remark- 
able cases,  many  of  which  are  recorded,  in  which  similar  malpositions 
occurred  in  many  successive  labors  ?  Thus  Joulin  refers  to  a  patient 
who  had  an  arm  presentation  in  three  successive  pregnancies,  and  to 
another  who  had  shoulder  presentation  in  three  out  of  four  labors. 
Certainly,  such  constant  recurrences  of  the  same  abnormality  could 
only  be  explained  on  the  hypothesis  of  some  very  persistent  cause, 
such  as  that  referred  to.  It  is  probable  that  merely  accidental  causes 
have  most  influence  in  the  production  of  shoulder  presentation,  such 
as  falls,  or  undue  pressure  exerted  on  the  abdomen  by  badly  fitting 
or  tight  stays.  Partially  transverse  positions  during  pregnancy  are 
certainly  much  more  common  than  is  generally  believed,  and  may 
often  be  detected  by  abdominal  palpation.  The  tendency  is  for  such 
malpositions  to  be  righted  either  before  labor  sets  in,  or  in  the  early 
period  of  labor ;  but  it  is  quite  easy  to  understand  how  any  persist- 
ent pressure,  applied  in  the  manner  indicated,  may  perpetuate  a 
position  which  otherwise  would  have  been  only  temporory. 

Prognosis  and  Frequency. — According  to  Churchill's  statistics, 
shoulder  presentations  occur  about  once  in  260  cases,  that  is  only 
slightly  less  frequently  than  those  of  the  face.  The  prognosis  to 
both  the  mother  and  child  is  much  more  unfavorable ;  for  he  esti- 
mates that  out  of  235  cases  1  in  9  of  the  mothers,  and  half  the 
children  were  lost.  The  prognosis  in  each  individual  case  will,  of 
course,  vary  much  with  the  period  of  delivery  at  which  the  malposi- 
tion is  recognized.  If  detected  early,  interference  is  easy,  and  the 
prognosis  ought  to  be  good ;  whereas  there  are  few  obstetric  diffi- 
culties more  trying  than  a  case  of  shoulder  presentation,  in  which 
the  necessary  treatment  has  been  delayed  until  the  presenting  part 
has  been  tightly  jammed  into  the  cavity  of  the  pelvis. 

Diagnosis. — Bearing  this  fact  in  mind,  the  paramount  necessity  of 
an  accurate  diagnosis  will  be  apparent;  and  it  is  specially  important 
that  we  should  be  able  not  only  to  detect  that  a  shoulder  or  arm  is 
presenting,  but  that  we  should,  if  possible,  determine  which  it  is,  and 
how  the  body  and  head  of  the  child  are  placed.  The  existence  of  a 
shoulder  presentation  is  not  generally  suspected,  until  the  first  vaginal 
examination  is  made  during  labor.  The  practitioner  will  then  be 
struck  with  the  absence  of  the  rounded  mass  of  the  fcetal  head,  and, 
if  the  os  be  open  and  the  membranes  protruding,  by  their  elongated 
form,  which  is  common  to  this  and  to  other  malpresentations.  If 
the  presenting  part  be  too  high  to  reach,  as  is  often  the  case  at  an 
early  period  of  labor,  an  endeavor  should  at  once  be  made  to  ascer- 


PRESENTATIONS  OF  SHOULDER,  ETC.  813 

tain  the  foetal  position  by  abdominal  examination.  This  is  the  more 
important,  as  it  is  much  more  easy  to  recognize  presentations  of  the 
shoulder  in  this  way  than  those  of  the  breech  or  foot;  and,  at  so 
early  a  period,  it  is  often  not  only  possible,  but  comparatively  easy, 
to  alter  the  position  of  the  foetus  by  abdominal  manipulation  alone, 
and  thus  avoid  the  necessity  of  the  more  serious  form  of  version. 
The  method  of  detecting  a  shoulder  presentation  by  examination  of 
the  abdomen  has  already  been  described  (p.  113),  and  need  not  be 
repeated.  The  chief  points  to  look  for  are,  the  altered  shape  of  the 
uterus,  and  two  solid  masses,  the  head  and  the  breech,  one  in  either 
iliac  fossa.  The  facility  with  which  these  parts  may  be  recognized 
varies  much  in  different  patients.  In  thin  women,  with  lax  abdominal 
parietes,  they  can  be  easily  felt;  while  in  very  stout  women,  it  may 
be  impossible.  Failing  this  method,  we  must  rely  on  vaginal  exami- 
nations ;  although,  before  the  membranes  are  ruptured,  and  when  the 
presenting  part  is  high  in  the  pelvis,  it  is  not  always  easy  to  gain 
accurate  information  in  this  way.  The  difficulty  is  increased  by  the 
paramount  importance  of  retaining  the  membranes  intact  as  long  as 
possible.  It  should  be  remembered,  therefore,  that  when  a  presenta- 
tion of  the  superior  extremity  is  suspected,  the  necessary  examinations 
should  only  be  made  in  the  intervals  between  the  pains,  when  the 
membranes  are  lax,  and  never  when  they  are  rendered  tense  by  the 
uterine  contractions. 

As  either  the  shoulder,  the  elbow,  or  the  hand,  may  present,  it 
will  be  best  to  describe  the  peculiarities  of  each  separately,  and  the 
means  of  distinguishing  to  which  side  of  the  body  the  presenting 
part  belongs. 

1.  The  shoulder  is  recognized  as  a  round  smooth  prominence,  at 
one  point  of  which  may  often  be  felt  the  sharp  edge  of  the  acromion. 
If  the  finger  can  be  passed  sufficiently  high,  it  may  be  possible  to  feel 
the  clavicle,  and  the  spine  of  the  scapula.  A  still  more  complete 
examination  may  enable  us  to  detect  the  ribs  and  the  intercostal 
spaces,  which  would  be  quite  conclusive  as  to  the  nature  of  the 
presentation,  since  there  is  nothing  resembling  them  in  any  other 
part  of  the  body.  At  the  side  of  the  shoulder,  the  hollow  of  the 
axilla  may  generally  be  made  out. 

Mode  of  Diagnosing  the  Position  of  the  Child. — In  order  to  ascer- 
tain the  position  of  the  child  we  have  to  find  out  in  which  iliac  fossa 
the  head  lies.  This  may  be  done  in  two  ways:  1st,  The  head  may 
be  felt  through  the  abdominal  parietes  by  palpation;  and  2d,  since 
the  axilla  always  points  towards  the  feet,  if  it  point  to  the  left  side 
the  head  must  lie  in  the  right  iliac  fossa,  if  to  the  right,  the  head 
must  be  placed  in  the  left  iliac  fossa.  Again,  the  spine  of  the  scapula 
must  correspond  to  the  back  of  the  child,  the  clavicle  to  its  abdomen; 
and,  by  feeling  one  or  other,  we  know  whether  we  have  to  do  with 
a  dorso-anterior  or  dorso-posterior  position.  If  we  cannot  satisfac- 
torily determine  the  position  by  these  means,  it  is  quite  legitimate 
practice  to  bring  down  the  arm  carefully,  provided  the  membranes 
are  ruptured,  so  as  to  examine  the  hand,  which  will  be  easily  recog- 
nized as  right  or  left.  This  expedient  will  decide  the  point;  but  it 
21 


314  LABOR. 

is  one  which  it  is  better  to  avoid,  if  possible,  for  it  not  only  slightly 
increases  the  difficulty  of  turning,  although  perhaps  not  very  mate- 
rially, but  the  arm  might  possibly  be  injured  in  the  endeavor  to  bring 
it  down. 

Differential  Diagnosis  of  the  Shoulder. — The  only  part  of  the  body 
likely  to  be  taken  for  the  shoulder  is  the  breech;  but  in  that  its 
larger  size,  the  groove  in  which  the  genital  organs  lie,  the  second 
prominence  formed  by  the  other  buttock,  and  the  sacral  spinous 
processes  are  sufficient  to  prevent  a  mistake. 

2.  The  elbow  is  rarely  felt  at  the  os,  and  may  be  readily  recognized 
by  the  sharp  prominence  of  the  olecranon,  situated  between  two  lc.-.-rr 
prominences,  the  condyles.     As  the  elbow  always  points  towards  the 
feet,  the  position  of  the  foetus  can  be  easily  ascertained. 

3.  The  hand  is  easy  to  recognize,  and  can  only  be  confounded  with 
the  foot.     It  can  be  distinguished  by  its  borders  being  of  the  same 
thickness,  by  the  fingers  being  wider  apart  and  more  readily  sepa- 
rated from  each  other  than  the  toes,  and  above  all  by  the  mobility 
of  the  thumb,  which  can  be  carried  across  the  palm,  and  placed  in 
apposition  with  each  of  the  fingers. 

Mode  of  Detecting  which  Hand  is  Presenting. — It  is  not  difficult  to 
tell  which  hand  is  presenting.  If  the  hand  be  in  the  vagina,  or 
beyond  the  vulva,  and  within  easy  reach,  we  recognize  which  it  is  by 
laying  hold  of  it  as  if  we  were  about  to  shake  hands.  If  the  palm 
lie  in  the  palm  of  the  practitioner's  hand,  with  the  two  thumbs  in 
apposition,  it  is  the  right  hand ;  if  the  back  of  the  hand,  it  is  the  left. 
Another  simple  way  is,  for  the  practitioner  to  imagine  his  own  hand 
placed  in  precisely  the  same  position  as  that  of  the  foetus ;  and  this 
will  readily  enable  him  to  verify  the  previous  diagnosis.  A  simple 
rule  tells  us  how  the  body  of  the  child  is  placed,  for,  provided  we 
are  sure  the  hand  is  in  a  state  of  supination,  the  back  of  the  hand 
points  to  the  back  of  the  child,  the  palm  to  its  abdomen,  the  thumb 
to  the  head,  and  the  little  finger  to  the  feet. 

Mechanism. — It  is  perhaps  hardly  proper  to  talk  of  a  mechanism 
of  shoulder  presentations,  since,  if  left  unassisted,  they  almost  inva- 
riably lead  to  the  gravest  consequences.  Still,  nature  is  not  entirely 
at  fault  even  here,  and  it  is  well  to  study  the  means  she  adopts  to 
terminate  these  malpositions. 

Terminations. — There  are  two  possible  terminations  of  shoulder 
presentation.  In  one,  known  as  "  spontaneous  version,"  some  other 
part  of  the  foetus  is  substituted  for  that  originally  presenting ;  in 
the  other,  "spontaneous  evolution"  the  foetus  is  expelled  by  being 
squeezed  through  the  pelvis,  without  the  originally  presenting  part 
being  withdrawn.  It  cannot  be  two  strongly  impressed  on  the  mind 
that  neither  of  these  can  be  relied  on  in  practice. 

Spontaneous  version  may  occasionally  occur  before,  or  immediately 
after,  the  rupture  of  the  membranes,  when  the  foetus  is  still  readily 
movable  within  the  cavity  of  the  uterus.  A  few  authenticated 
cases  are  recorded  in  which  the  same  fortunate  issue  took  place  after 
the  shoulder  had  been  engaged  in  the  pelvic  brim  for  a  considerable 
time,  or  even  after  prolapse  of  the  arm  ;  but  its  probability  is  neces- 


PRESENTATIONS  OF  SHOULDER,  ETC.  315 

sarily  much  lessened  under  sucli  circumstances.  Either  the  head  or 
the  breech  may  be  brought  down  to  the  os  in  place  of  the  original 
presentation. 

The  precise  mechanism  of  spontaneous  version,  or  the  favoring 
circumstances,  are  not  sufficiently  understood  to  justify  any  positive 
statement  with  regard  to  it. 

Cazeaux  believed  that  it  is  produced  by  partial  or  irregular  con- 
traction of  the  uterus,  one  side  contracting  energetically,  while  the 
other  remains  inert,  or  only  contracts  to  a  slight  degree.  To  illus- 
trate how  this  may  effect  spontaneous  version,  let  us  suppose  that 
the  child  is  lying  with  the  head  in  the  left  iliac  fossa.  Then  if  the 
left  side  of  the  uterus  should  contract  more  forcibly  than  the  right, 
it  would  clearly  tend  to  push  the  head  and  shoulder  to  the  right  side, 
until  the  head  carne  to  present  instead  of  the  shoulder.  A  very  in- 
teresting case  is  related  by  Geneuil,1  in  which  he  was  present  during 
spontaneous  version,  in  the  course  of  which  the  breech  was  substi- 
tuted for  the  left  shoulder  more  than  four  hours  after  the  rupture  of 
the  membranes.  In  this  case  the  uterus  was  so  tightly  contracted 
that  version  was  impossible.  He  observed  the  side  of  the  uterus 
opposite  the  head  contracting  energetically,  the  other  remaining  flac- 
cid, and  eventually  the  case  ended  without  assistance,  the  breech  pre- 
senting. The  natural  moulding  action  of  the  uterus,  and  the  greater 
tendency  of  the  long  axis  of  the  child  to  lie  in  that  of  the  uterus,  no 
doubt  assist  the  transformation,  and  much  must  depend  on  the  mo- 
bility of  the  foetus  in  any  individual  case. 

That  such  changes  often  take  place  in  the  latter  weeks  of  preg- 
nancy, and  before  labor  has  actually  commenced,  is  quite  certain,  and 
they  are  probably  much  more  frequent  than  is  generally  supposed. 
When  spontaneous  version  does  occur,  it  is,  of  course,  a  most  favor- 
able event ;  and  the  termination  and  prognosis  of  the  labor  are  then 
the  same  as  if  the  head  or  breech  had  originally  presented. 

Spontaneous  Evolution. — The  mechanism  of  spontaneous  evolution, 
since  it  was  first  clearly  worked  out  by  Douglas,  has  been  so  often 
and  carefully  described,  that  we  know  precisely  how  it  occurs.  Al- 
though every  now  and  then  a  case  is  recorded  in  which  a  living 
child  has  been  born  by  this  means,  such  an  event  is  of  extreme 
rarity ;  and  there  is  no  doubt  of  the  accuracy  of  the  general  opinion, 
that  spontaneous  evolution  can  only  happen  when  the  pelvis  is  un- 
usually roomy  and  the  child  small ;  and  that  it  almost  necessarily 
involves  the  death  of  the  foetus,  on  account  of  the  immense  pressure 
to  which  it  is  subjected. 

Two  varieties  are  described,  in  one  of  which  the  head  is  first  born, 
in  the  other  the  breech ;  in  both  the  originally  presenting  arm  re- 
mains prolapsed.  The  former  is  of  extreme  rarity,  and  is  believed 
only  to  have  happened  with  very  premature  children,  whose  bodies 
were  small  and  flexible,  and  when  traction  had  been  made  on  the 
presenting  arm.  Under  such  circumstances  it  can  hardly  be  called  a 

1   Ann.  de  Gyn6ologie,  v.  v.  1876. 


316 


LABOR. 


natural  process,  and  we  may  confine  our  attention  to  the  latter  and 
more  common  variety. 

What  takes  place  is  as  follows:  The  presenting  arm  and  shoulder 
are  tightly  jammed  down,  as  far  as  is  possible,  by  the  uterine  con- 
tractions, and  the  head  becomes  strongly  flexed  on  the  shoulder.  As 


FIG.  113. 


Commencing  Spontaneous  Evolution. 


much  of  the  body  of  the  foetus  as  the  pelvis  will  contain  becomes 
engaged,  and  then  a  movement  of  rotation  occurs,  which  brings  the 
body  of  the  child  nearly  into  the  antero-posterior  diameter  of  the 
pelvis  (Fig.  113).  The  shoulder  now  projects  under  the  arch  of  the 


FIG.  114. 


Spontaneous  Evolution  further  advanced. 


pubis,  the  head  lying  above  the  symphysis,  and  the  breech  near  the 
sacro-iliac  synchondrosis.     The  shoulder  and  neck  of  the  child  now 


PRESENTATIONS  OF  SHOULDER,  ETC.  317 

become  fixed  points,  round  Avhicli  the  body  of  the  child  rotates,  and 
the  whole  force  of  the  uterine  contractions  is  expended  on  the 
breech.  The  latter,  with  the  body,  therefore,  becomes  more  and 
more  depressed,  until,  at  last,  the  side  of  the  thorax  reaches  the  vulva, 
and,  followed  by  the  breech  and  inferior  extremities,  is  slowly  pushed 
out  (Fig.  114).  As  soon  as  the  limbs  are  born  the  head  is  easily  ex- 
pelled. 

The  enormous  pressure  to  which  the  body  is  subjected  in  this 
process  can  readily  be  understood.  As  regards  the  practical  bearings 
of  this  termination  of  shoulder  presentations,  all  that  need  be  said 
is,  that,  if  we  should  happen  to  meet  with  a  case  in  which  the 
shoulder  and  thorax  were  so  strongly  depressed  that  turning  was 
impossible,  and  in  which  it  seemed  that  nature  was  endeavoring  to 
effect  evolution,  we  would  be  justified  in  aiding  the  descent  of  the 
breech  by  traction  on  the  groin,  before  resorting  to  the  difficult  and 
hazardous  operation  of  embryotomy  or  decapitation. 

Treatment. — It  is  unnecessary  to  describe  specially  the  treatment 
of  shoulder  presentation,  since  it  consists  essentially  in  performing 
the  operation  of  turning,  which  is  fully  described  elsewhere.  It  is 
only  needful  here  to  insist  on  the  advisability  of  performing  the 
operation  in  the  way  which  involves  the  least  interference  with  the 
uterus.  Hence  if  the  nature  of  the  case  be  detected  before  the  mem- 
branes are  ruptured,  an  endeavor  should  be  made — and  ought  gen- 
erally to  succeed — to  turn  by  external  manipulation  only.  If  we  can 
succeed  in  bringing  the  breech,  or  head  over  the  os  in  this  way,  the 
case  will  be  little  more  troublesome  than  an  ordinary  presentation 
of  these  parts.  Failing  in  this,  turning  by  combined  external  and 
internal  manipulation  should  be  attempted  ;  and  the  introduction  of 
the  entire  hand  should  be  reserved  for  those  more  troublesome  cases 
in  which  the  waters  have  long  drained  away,  and  in  which  both 
these  methods  are  inapplicable. 

Should  all  these  means  fail,  we  have  no  resource  but  the  mutilation 
of  the  child  by  embryulcia  or  decapitation,  probably  the  most  diffi- 
cult and  dangerous  of  all  obstetric  operations.  [In  seven  instances 
in  the  United  States,  where  there  was  no  special  deformity,  the 
Csesarean  operation  was  resorted  to,  with  a  saving  of  life  in.  six  of 
the  women.  The  one  that  died  had  been  26  hours  under  a  midwife, 
who  had  administered  ergot :  death  from  exhaustion  in  12  hours. — 
ED.] 

Complex  Presentations. — There  are  various  so-called  complex  pre- 
sentations in  which  more  than  one  part  of  the  foetal  body  presents. 
Thus  we  may  have  a  hand  or  a  foot  presenting  with  the  head,  or  a 
foot  and  hand  presenting  simultaneously.  The  former  do  not  neces- 
sarily give  rise  to  any  serious  difficulty,  for  there  is  generally  suffi- 
cient room  for  the  head  to  pass.  Indeed  it  is  unlikely  that  either 
the  hand  or  foot  should  enter  the  pelvic  brim  with  the  head,  unless 
the  head  was  unusually  small,  or  the  pelvis  more  than  ordinarily 
capacious.  As  regards  treatment,  it  is,  no  doubt,  advisable  to  make 
an  attempt  to  replace  the  hand  or  foot  by  pushing  it  gently  above 
the  head  in  the  intervals  between  the  pains,  and  maintaining  it  there 


318 


LABOR. 


FIG.  115. 


until  the  head  be  fully  engaged  in  the  pelvic  cavity.  The  engage- 
ment of  the  head  can  be  hastened  by  abdominal  pressure,  which  will 
prove  of  great  value.  Failing  this,  all  we  can  do  is  to  place  the 
presenting  member  at  the  part  of  the  pelvis  where  it  will  least  im- 
pede the  labor,  and  be  the  least  subjected  to  pressure ;  and  that  will 
generally  be  opposite  the  temple  of  the  child.  As  it  must  obstruct 
the  passage  of  the  head  to  a  certain  extent,  the  application  of  the 
forceps  may  be  necessary.  When  the  feet  and  hands  present  at  the 
same  time,  in  addition  to  the  confusing  nature  of  the  presentation 
from  so  many  parts  being  felt  together,  there  is  the  risk  of  the  hands 
coming  down,  and  converting  the  case  into  one  of  arm  presentation. 
It  is  the  obvious  duty  of  the  accoucheur  to  prevent  this  by  insuring 
the  descent  of  the  feet,  and  traction  should  be  made  on  them,  either 
with  the  fingers  or  with  a  lac,  until  their  descent,  and  the  ascent  of 
the  hands,  are  assured. 

Dorsal  Displacement  of  the  Arm. — In  connection  with  this  subject 
may  be  mentioned  the  curious  dorsal  displacement  of  the  arm  first 
described  by  Sir  James  Simpson,1  in  which  the  forearm  of  the  child 
becomes  thrown  across  and  behind  the  neck.  The  result  is  the  for- 
mation of  a  ridge  or  bar,  which  prevents  the  descent  of  the  head  into 

the  pelvis  by  hitching  against  the  brim  (Fig. 
115).  The  difficulty  of  diagnosis  is  very 
great,  for  the  cause  of  obstruction  is  too 
high  up  to  be  felt.  But  if  we  meet  with  a 
case  in  which  the  pelvis  is  roomy  and  the 
pains  strong,  and  yet  the  head  does  not  de- 
scend after  an  adequate  time,  a  full  explora- 
tion of  the  cause  is  essential.  For  this  pur- 
pose we  would  naturally  put  the  patient 
under  chloroform,  and  pass  the  hand  suffi- 
ciently high.  We  might  then  feel  the  arm 
in  its  abnormal  position.  That  was  what 
took  place  in  a  case  under  my  own  care,  in 
which  I  failed  to  get  the  head  through  the 
brim  with  the  forceps,  and  eventually  de- 
livered by  turning.  The  same  course  was 
adopted  by  my  friend  Mr.  Jardine  Murray 
in  a  similar  case.2  Simpson  advises  that  the 
arm  should  be  brought  down  so  as  to  con- 
vert the  case  into  an  ordinary  hand  and 
head  presentation.  This,  if  the  arm  be 
above  the  brim,  must  always  be  difficult, 
and  I  believe  the  simpler  and  more  effective 
plan  is  podalic  version.  A  similar  displacement  may  cause  some 
difficulty  in  breech  presentations,  and  after  turning  (Fig.  116).  Delay 
here  is  easier  of  diagnosis,  since  the  obstacle  to  the  expulsion  will  at 
once  lead  to  careful  examination.  By  carrying  the  body  of  the  child 
well  backwards,  so  as  to  enable  the  finger  to  pass  behind  the  sym- 


Dorsal  Displacement  of  the  Anns. 


1  Selected  Obst.  Works,  vol.  i. 


2  Med.  Times  and  Gaz.,  1861. 


PRESENTATIONS    OF    SHOULDER,    ETC, 


319 


physis  pubis  and  over  the  shoulder,  it  will  generally  be  easy  to 
liberate  the  arm. 


Dorsal  Displacement  of  the  Arms  in  Footling  Presentations.     (After  Barnes.) 

Prolapse  of  the  Umbilical  Cord. — It  occasionally  happens  that  the 
•umbilical  cord  falls  down  past  the  presenting  part  (Fig.  117),  and  is 
apt  to  be  pressed  between  it  and  the  walls  of  the  pelvis.  The  con- 
sequence is,  that  the  foetal  circulation  is  seriously  interfered  with, 
and  the  death  of  the  child  from  asphyxia  is  a  common  result.  Hence 
prolapse  of  the  funis  is  a  very  serious  complication  of  labor  in  so  far 
as  the  child  is  concerned. 

Frequency. — Fortunately  it  is  not  a  very  frequent  occurrence. 
Churchill  calculates  that  out  of  over  105,000  deliveries  it  was  met 
with  once  in  240  cases,  and  Scanzoni  once  in  254.  Its  frequency 
varies  much  under  different  circumstances,  and  in  different  places. 
We  find  from  Churchill's  figures  a  remarkable  difference  in  the  pro- 
portional number  of  cases  observed  in  France,  England,  and  Germany, 
viz.,  1  in  446J,  1  in  207J,  and  1  in  156,  respectively.  Great  as  is 
the  proportion  referred  to  Germany  in  these  figures,  it  has  been 
found  to  be  exceeded  in  special  districts.  Thus  Engelman  records  1 
case  out  of  94  labors  in  the  Lying-in  Hospital  at  Berlin,  and  Michaelis 
1  in  90  in  that  of  Kiel.  These  remarkable  differences  are  at  first 
sight  not  easy  to  account  for.  Dr.  Simpson  suggests,  with  consider- 
able show  of  probability,  that  the  difference  in  frequency  in  England, 


320  LABOR. 

France,  and  Germany,  may  depend  on  the  varying  positions  in  which 
lying-in  women  are  placed  during  labor  in  each  country.  In  France, 
where,  although  the  patient  is  laid  on  her  back,  the  pelvis  is  kept 


FIG.  117. 


Prolapse  of  the  Umbilical  Cord. 

elevated,  the  complication  occurs  least  frequently ;  in  England,  where 
she  lies  on  her  side,  more  often  ;  and  in  Germany,  where  she  is 
placed  on  her  back  with  her  shoulders  raised,  most  often.  The 
special  frequency  of  prolapsed  funis  in  certain  districts,  as  in  Kiel,  is 
supposed  by  Engelman1  to  depend  on  the  prevalence  of  rickets,  and 
consequently  of  deformed  pelvis,  which  we  shall  presently  see  is 
probably  one  of  the  most  frequent  and  important  causes  of  the 
accident. 

Prognosis. — "With  regard  to  the  danger  attending  prolapsed  funis, 
as  far  as  the  mother  is  concerned,  it  may  be  said  to  be  altogether 
unimportant;  but  the  universal  experience  of  obstetricians  points  to 
the  great  risk  to  which  the  child  is  subjected.  Scanzoni  calculates 
that  45  per  cent,  only  of  the  children  were  saved  ;  Churchill  estimated 
the  number  at  47  per  cent. ;  thus,  under  the  most  favorable  circum- 
stances, this  complication  leads  to  the  death  of  more  than  half  the 
children.  Engelman  found  that  out  of  202  vertex  presentations  only 
86  per  cent,  of  the  children  survived.  The  mortality  was  not  nearly 
so  great  in  other  presentations ;  68  per  cent,  of  the  cases  in  which 
the  child  presented  with  the  feet  were  saved,  and  50  per  cent,  in 
original  shoulder  presentations.  The  reason  of  this  remarkable  dif- 
ference is,  doubtless,  that  in  vertex  presentations  the  head  fits  the 
pelvis  much  more  completely,  and  subjects  the  cord  to  much  greater 

1  Amer.  Journ.  of  Obst.,  vol.  vi. 


PRESENTATIONS  OF  SHOULDER,  ETC.  321 

pressure ;  while  in  other  presentations  the  pelvis  is  less  completely 
filled,  and  the  interference  with  the  circulation  in  the  cord  is  not  so 
great.  Besides,  in  the  latter  case,  the  complication  is  detected  early, 
and  the  necessary  treatment  sooner  adopted. 

The  fcetal  mortality  is  considerably  greater  in  first  labors ;  a  result 
to  be  expected  on  account  of  the  greater  resistance  of  the  soft  parts, 
and  the  consequent  prolongation  of  the  labor. 

Causes. — The  causes  of  prolapse  of  the  funis  are  any  circumstances 
which  prevent  the  presenting  part  accurately  fitting  the  pelvic  brim. 
Hence  it  is  much  more  frequent  in  face,  breech,  or  shoulder,  than  in 
vertex  presentations,  and  is  relatively  more  common  in  footling  and 
shoulder  presentations  than  in  any  other.  Amongst  occasional  acci- 
dental predisposing  causes  may  be  mentioned  early  rupture  of  the 
membranes,  especially  if  the  amount  of  liquor  amnii  be  excessive,  as 
the  sudden  escape  of  the  fluid  washes  down  the  cord;  undue  length 
of  the  cord  itself;  or  an  unusually  low  placental  attachment.  Engel- 
rnan  attaches  great  importance  to  slight  contraction  of  the  pelvis, 
and  states  that  in  the  Berlin  Lying-in  Hospital,  where  accurate 
measurements  of  the  pelvis  were  taken  in  all  cases,  it  was  almost 
invariably  found  to  exist.  The  explanation  is  evident,  since  one  of 
the  first  results  of  pelvic  contraction  is  to  prevent  the  ready  engage- 
ment of  the  presenting  part  in  the  pelvic  brim. 

Diagnosis. — The  diagnosis  of  cord  presentation  is  generally  devoid 
of  difficulty;  but  if  the  membranes  are  still  unruptured,  it  may  not 
always  be  quite  easy  to  determine  the  precise  nature  of  trie  soft 
structures  felt  through  them,  as  they  recede  from  the  touch.  If  the 
pulsations  of  the  cord  can  be  felt  through  the -membranes,  all  diffi- 
culty is  removed.  After  the  membranes  are  ruptured,  there  is 
nothing  that  it  can  well  be  mistaken  for. 

Importance  of  Determining  the  Pulsations  of  the  Cord. — The  im- 
portant point  to  determine  in  such  a  case  is  whether  the  cord  be 
pulsating  or  not ;  for  if  pulsations  have  entirely  ceased,  the  inference 
is  that  the  child  is  dead,  and  the  case  may  then  be  left  to  nature 
without  further  interference.  It  is  of  importance,  however,  to  be 
careful;  for,  if  the  examination  be  made  during  a  pain,  the  circula- 
tion might  be  only  temporarily  arrested.  The  examination,  there- 
fore, should  be  made  during  an  interval,  and  a  loop  of  the  cord 
pulled  down,  if  necessary,  to  make  ourselves  absolutely  certain  on 
this  point. 

Amount  of  Cord  Prolapsed. — The  amount  of  the  prolapse  varies 
much.  Sometimes  only  a  knuckle  of  the  cord,  so  small  as  to  escape 
observation,  is  engaged  between  the  pelvis  and  presenting  part. 
Under  such  circumstances  the  child  may  be  sacrificed  without  any 
suspicion  of  danger  having  arisen.  More  often  the  amount  pro- 
lapsed is  considerable;  sometimes  so  as  to  lie  in  the  vagina  in  a  long 
loop,  or  even  to  protrude  altogether  beyond  the  vulva. 

Treatment. — In  the  treatment  the  great  indication  is  to  prevent  the 
cord  from  being  unduly  pressed  on,  and  all  our  endeavors  must  have 
this  object  in  view.  If  the  presentation  be  detected  before  the  full 
dilatation  of  the  cervix,  and  when  the  membranes  are  unruptured, 


822 


LABOR. 


we  must  try  to  keep  the  cord  out  of  the  way ;  to  preserve  the  mem- 
branes intact  as  long  as  possible,  since  the  cord  is  tolerably  protected 
as  long  as  it  is  surrounded  by  the  liquor  amnii ;  and  to  secure  the 
complete  dilatation  of  the  os,  so  that  the  presenting  part  may  engage 
rapidly  and  completely. 

Postural  Treatment. — Much  may  be  done  at  this  time  by  the  pos- 
tural treatment,  which  we  chiefly  owe  to  the  ingenuity  of  Dr.  Gail- 
lard  Thomas,  of  New  York,  whose  writings  familiarized  the  profession 
with  it,  although  it  appears  that  a  somewhat  similar  plan  had  been 
occasionally  adopted  previously.  Dr.  Thomas's  method  is  based  on 
the  principle  of  causing  the  cord  to  slip  back  into  the  uterine  cavity 
by  its  own  weight.  For  this  purpose  the  patient  is  placed  on  her 
hands  and  knees,  with  the  hips  elevated,  and  the  shoulders  resting 
on  a  lower  level  (Fig.  118).  The  cervix  is  then  no  longer  the  most 

FIG.  118. 


Postural  Treatment  of  Prolapse  of  the  Cord. 

dependent  portion  of  the  uterus,  and  the  anterior  wall  of  the  uterus 
forms  an  inclined  plane  down  which  the  cord  slips.  The  success  of 
this  manoeuvre  is  sometimes  very  great,  but  by  no  means  always  so. 
It  is  most  likely  to  succeed  when  the  membranes  are  unruptured. 
If,  when  adopted,  the  cord  slip  away,  and  the  os  be  sufficiently  dilated, 
the  membranes  may  be  ruptured,  and  engagement  of  the  head  pro- 
duced by  properly  applied  uterine  pressure.  Sometimes  the  position 
is  so  irksome  that  it  is  impossible  to  resort  to  it.  Postural  treatment 
is  not  even  then  altogether  impossible,  for  by  placing  the  patient  on 
the  side  opposite  to  that  of  the  prolapse,  so  as  to  relieve  the  cord  as 
much  as  possible  from  pressure,  arid  at  the  same  time  elevating  the 
hips  by  a  pillow,  it  may  slip  back.  Even  after  the  membranes  are 
ruptured,  postural  treatment  in  one  form  or  another  may  succeed  ; 
and,  as  it  is  simple  and  harmless,  it  should  certainly  be  always  tried. 
Attempts  at  reposition,  by  one  or  other  of  the  methods  described 
below,  may  also  occasionally  be  facilitated  by  trying  them  when  the 
patient  is  placed  in  the  knee-shoulder  position. 


PRESENTATIONS    OF    SHOULDER,    ETC. 


323 


FIG.  119. 


Artificial  Reposition. — Failing  by  postural  treatment,  or  in  combi- 
nation with  it,  it  is  quite  legitimate  to  make  an  attempt  to  place  the 
cord  beyond  the  reach  of  dangerous  pressure  by  other  methods. 
Unfortunately  reposition  is  too  often  disappointing,  difficult  to  effect, 
and  very  frequently,  even  when  apparently  successful,  shortly 
followed  by  a  fresh  descent  of  the  cord.  Provided  the  os  be  fully 
dilated,  and  the  presenting  head  engaged  in  the  pelvis  (for  reposition 
may  be  said  to  be  hopeless  when  any  other  part  presents),  perhaps 
the  best  way  is  to  attempt  it  by  the  hand  alone.  Probably  the 
simplest  and  most  effectual  method  is  that  recommended  by  McClin- 
tock  and  Hardy,  who  advise  that  the  patient 
should  lie  on  the  opposite  side  to  the  prolapsed 
cord,  which  should  then  be  drawn  towards  the 
pubis  as  being  the  shallowest  part  of  the  pelvis. 
Two  or  three  fingers  may  then  be  used  to  push 
the  cord  past  the  head,  and  as  high  as  they  can 
reach.  They  must  be  kept  in  the  pelvis  until  a 
pain  comes  on,  and  then  very  gently  withdrawn, 
in  the  hope  that  the  cord  may  not  again  prolapse. 
During  the  pain  external  pressure  may  very 
properly  be  applied  to  favor  descent  of  the  head. 
This  manoeuvre  may  be  repeated  during  several 
successive  .pains,  and  may  eventually  succeed. 
The  attempt  to  hook  the  cord  over  the  foetal  limbs, 
or  to  place  it  in  the  hollow  of  the  neck,  recom- 
mended in  many  works,  involves  so  deep  an  in- 
troduction of  the  hand,  that  it  is  obviously  im- 
practicable. 

Instruments  Used  for  Reposition. — Various  com- 
plex instruments  have  been  invented  to  aid  repo- 
sition (Fig.  119),  but  even  if  we  possessed  them, 
they  are  not  likely  to  be  at  hand  when  the  emer- 
gency arises.  A  simple  instrument  may  be  im- 
provised out  of  an  ordinary  male  elastic  catheter, 
by  passing  the  two  ends  of  a  piece  of  string 
through  it,  so  as  to  leave  a  loop  emerging  from 
the  eye  of  the  catheter.  This  is  passed  through 
the  loop  of  prolapsed  cord,  and  then  fixed  in  the 
eye  of  the  catheter  by  means  of  the  stilette.  The 
cord  is  then  pushed  up  into  the  uterine  cavity  by  the  catheter,  and 
liberated  by  withdrawing  the  stilette.  Another  simple  instrument 
may  be  made  by  cutting  a  hole  in  a  piece  of  whalebone.  A  piece  of 
tape  is  then  passed  through  the  loop  of  the  cord,  and  the  ends  threaded 
through  the  eye  cut  in  the  whalebone.  By  tightening  the  tape  the 
whalebone  is  held  in  close  apposition  to  the  cord,  and  the  whole  is 
passed  as  high  as  possible  into  the  uterine  cavity.  The  tape  can 
easily  be  liberated  by  pulling  one  end.  If  preferred,  the  cord  can  be 
tied  to  the  whalebone,  which  is  left  in  utero  until  the  child  is  born. 
Nothing  need  be  said  as  to  the  various  other  methods  adopted  for 
keeping  up  the  cord,  such  as  the  insertion  of  pieces  of  sponge,  or 


Braun's    Apparatus    for 
Replacing  the  Cord. 


324  LABOR. 

tying  the  cord  in  a  bag  of  soft  leather,  since  they  are  generally  ad- 
mitted to  be  quite  useless. 

Treatment  when  Reposition  Fails. — It  only  too  often  happens  that 
all  endeavors  at  reposition  fail.  The  subsequent  treatment  must 
then  be  guided  by  the  circumstances  of  the  case.  If  the  pelvis  be 
roomy,  and  the  pains  strong,  especially  in  a  multipara,  we  may  often 
deem  it  advisable  to  leave  the  case  to  nature,  in  the  hope  that  the 
head  may  be  pushed  through  before  pressure  on  the  cord  has  had 
time  to  prove  fatal  to  the  child.  Under  such  circumstances  the 
patient  should  be  urged  to  bear  down,  and  the  descent  of  the  head 
promoted  by  uterine  pressure,  so  as  to  get  the  second  stage  com- 
pleted as  soon  as  possible.  If  the  head  be  within  easy  reach,  the 
application  of  the  forceps  is  quite  justifiable,  since  delay  must  neces- 
sarily involve  the  death  of  the  child.  During  this  time  the  cord 
should  be  placed,  if  possible,  opposite  one  or  other  sacro-iliac  syn- 
ch ondrosis,  according  to  the  position  of  the  head,  as  the  part  of  the 
pelvis  where  there  is  most  room,  and  where  the  pressure  would  conse- 
quently be  least  prejudicial.  If  we  have  to  do  with  a  case  in  which 
the  head  has  not  descended  into  the  pelvis,  and  postural  treatment 
and  reposition  have  both  failed,  provided  the  os  be  fully  dilated,  and 
other  circumstances  be  favorable,  turning  would  undoubtedly  offer 
the  best  chance  to  the  child.  This  treatment  is  strongly  advocated 
by  Engelman,  who  found  that  70  per  cent,  of  the  children  delivered 
in  this  way  were  saved.  There  can  be  no  question  that,  so  far  as  the 
interests  of  the  child  are  concerned,  it  is,  under  the  circumstances 
indicated,  by  far  the  best  expedient.  Turning,  however,  is  by  no 
means  always  devoid  of  a  certain  risk  to  the  mother,  and  the  per- 
formance of  the  operation,  in  any  particular  case,  must  be  left  to  the 
judgment  of  the  practitioner.  A  fully  dilated  os,  with  membranes 
unruptured,  so  that  version  could  be  performed  by  the  combined 
method  without  the  introduction  of  the  hand  into  the  uterus,  would 
be  unquestionably  the  most  favorable  state.  If  it  be  not  deemed 
proper  to  resort  to  it,  all  that  can  be  done  is  to  endeavor  to  save  the 
cord  from  pressure  as  much  as  possible,  by  one  or  other  of  the 
methods  already  mentioned. 


CHAPTER  IX. 

PROLONGED  AND  PRECIPITATE  LABORS. 

AMONG  the  difficulties  connected  with  parturition  there  are  none 
of  more  frequent  occurrence,  and  none  requiring  more  thorough 
knowledge  of  the  physiology  and  pathology  of  labor,  than  those 
arising  from  deficient  or  irregular  action  of  the  expulsive  powers. 


PROLONGED  AND  PRECIPITATE  LABORS.          825 

The  importance  of  studying  this  class  of  labors  will  be  seen  when  we 
consider  the  numerous  and  very  diverse  causes  which  produce  them. 

Evil  Effects  of  Prolonged  Labor. — That  the  mere  prolongation  of 
labor  is  in  itself  a  serious  thing,  is  becoming  daily  more  and  more  an 
acknowledged  axiom  of  midwifery  practice ;  and  that  this  is  so  is 
evident  when  we  contrast  the  statistical  returns  of  such  institutions 
as  the  Rotunda  Lying-in  Hospital  of  late  years,  with  those  which 
were  published  some  twenty  or  thirty  years  ago.  It  may  be  fairly 
assumed  that  the  practice  of  the  distinguished  heads  of  that  well- 
known  school  represents  the  most  advanced  and  scientific  opinion  of 
the  day.  When  we  find  that,  less  than  thirty  years  ago,  the  forceps 
were  not  used  more  than  once  in  310  labors,  while  according  to  the 
report  for  1873  the  late  Master  applied  them  once  in  8  labors,  it  is 
apparent  how  great  is  the  change  which  has  taken  place. 

Causes  of  Prolonged  Labor. — Labor  may  be  prolonged  from  an 
immense  number  of  causes,  the  principal  of  which  will  require  sepa- 
rate study.  Some  depend  simply  on  defective  or  irregular  action  of 
the  uterus ;  others  act  by  opposing  the  expulsion  of  the  child,  as,  for 
example,  undue  rigidity  of  the  parturient  passages,  tumors,  bony 
deformity,  and  the  like.  Whatever  the  source  of  delay,  a  train  of 
formidable  symptoms  are  developed,  which  are  fraught  with  peril 
both  to  the  mother  and  the  child.  As  regards  the  mother,  they  vary 
much  in  degree,  and  in  the  rapidity  with  which  they  become  estab- 
lished. In  many  cases,  in  which  the  action  of  the  uterus  is  slight,  it 
may  be  long  before  serious  results  follow ;  while  in  others,  in  which 
a  strongly-acting  organ  is  exhausting  itself  in  futile  endeavors  to 
overcome  an  obstacle,  the  worst  signs  of  protraction  may  come  on 
with  comparative  rapidity. 

The  Influence  of  the  Stage  of  Labor  in  Protraction. — The  stage  of 
labor  in  which  delay  occurs  has  a  marked  effect  in  the  production,  of 
untoward  symptoms.  It  is  a  well-established  fact  that  prolongation 
is  of  comparatively  small  consequence  to  either  the  mother  or  child 
in  the  first  stage,  when  the  membranes  are  still  intact,  and  when  the- 
soft  parts  of  the  mother,  as  well  as  the  body  of  the  child,  are  pro- 
tected by  the  liquor  amnii  from  injurious  pressure ;  whereas  if  the 
membranes  have  ruptured,  prolongation  becomes  of  the  utmost  im- 
portance to  both  as  soon  as  the  head  has  entered  the  pelvis,  when 
the  uterus  is  strongly  excited  by  reflex  stimulation,  when  the  mater- 
nal soft  parts  are  exposed  to  continuous  pressure,  and  when  the 
tightly-contracted  uterus  presses  firmly  on  the  foetus  and  obstructs 
the  placental  circulation.  It  is  in  reference  to  the  latter  class  of  cases 
that  the  change  of  practice,  already  alluded  to,  has  taken  place,  with 
the  most  beneficial  results  both  to  the  mother  and  child. 

It  must  not  be  assumed,  however,  that  prolongation  of  labor  is 
never  of  any  consequence  until  the  second  stage  has  commenced.. 
The  fallacy  of  such  an  opinion  was  long  ago  shown  by  Simpson,  who> 
proved,  in  the  most  conclusive  way,  that  both  the  maternal  and  foetal 
mortality  were  greatly  increased  in  proportion  to  the  entire  length 
of  the  labor  ;  and  all  practical  accoucheurs  are  familiar  with  cases  in 
which  symptoms  of  gravity  have  arisen  before  the  first  stage  is 


326  LABOR. 

concluded.  Still,  relatively  speaking,  the  opinion  indicated  is  un- 
doubtedly correct. 

In  the  present  chapter  we  have  to  do  only  with  those  causes  of 
delay  connected  with  the  expulsive  powers.  Inasmuch,  however,  as 
the  injurious  effects  of  protraction  are  similar  in  kind,  whatever  be 
the  cause,  it  will  save  needless  repetition  if  we  consider,  once  for  all, 
the  train  of  symptoms  that  arise  whenever  labor  is  unduly  prolonged. 

Delay  in  the  First  Stage. — As  long  as  the  delay  is  in  the  first  stage 
only,  with  rare  exceptions,  no  symptoms  of  real  gravity  arise  for  a 
length  of  time;  it  may  be  even  for  days.  There  is  often,  however, 
a  partial  cessation  of  the  pains,  which,  in  consequence  of  temporary 
exhaustion  of  nervous  force,  may  even  entirely  disappear  for  many 
consecutive  hours.  Under  such  circumstances,  after  a  period  of  rest, 
either  natural  or  produced  by  suitable  sedatives,  they  recur  with 
renewed  vigor. 

Symptoms  of  Protraction  in  the  Second  Stage. — A  similar  temporary 
cessation  of  the  pains  may  often  be  observed  after  the  head  has 
passed  through  the  os  uteri,  to  be  also  followed  by  renewed  vigorous 
action  after  rest.  But  now  any  such  irregularity  must  be  much  more 
anxiously  watched.  In  the  majority  of  cases  any  marked  alteration 
in  the  force  and  frequency  of  the  pains  at  this  period  indicates  a 
much  more  serious  form  of  delay,  which  in  no  long  time  is  accom- 
panied by  grave  general  symptoms.  The  pulse  begins  to  rise,  the 
skin  to  become  hot  and  dry,  the  patient  to  be  restless  and  irritable. 
The  longer  the  delay,  and  the  more  violent  the  efforts  of  the  uterus 
to  overcome  the  obstacle,  the  more  serious  does  the  state  of  the 
patient  become.  The  tongue  is  loaded  with  fur,  and,  in  the  worst 
cases,  dry  and  black ;  nausea  and  vomiting  often  become  marked ; 
the  vagina  feels  hot  and  dry,  the  ordinary  abundant  mucous  secre- 
tion being  absent ;  in  severe  cases  it  may  be  much  swollen,  and  if 
the  presenting  part  be  firmly  impacted,  a  slough  may  even  form. 
Should  the  patient  still  remain  undelivered,  all  these  symptoms  be- 
come greatly  intensified  ;  the  vomiting  is  incessant,  the  pulse  is  rapid 
and  almost  imperceptible,  low  muttering  delirium  supervenes,  and 
the  patient  eventually  dies  with  all  the  worst  indications  of  profound 
irritation  and  exhaustion. 

So  formidable  a  train  of  symptoms,  or  even  the  slighter  degrees  of 
them,  should  never  occur  in  the  practice  of  the  skilled  obstetrician ; 
and  it  is  precisely  because  a  more  scientific  knowledge  of  the  process 
of  parturition  has  taught  the  lesson  that,  under  such  circumstances, 
prevention  is  better  than  cure,  that  earlier  interference  has  become  so 
much  more  the  rule. 

Those  who  taught  that  nothing  should  be  done  until  nature  had 
had  every  possible  chance  of  effecting  delivery,  and  who,  therefore, 
allowed  their  patients  to  drag  on  in  many  weary  hours  of  labor,  at 
the  expense  of  great  exhaustion  to  themselves,  and  imminent  risk  to 
their  offspring,  made  much  capital  out  of  the  time-honored  maxim 
that  "  meddlesome  midwifery  is  bad."  When  this  proverb  is  applied 
to  restrain  the  rash  interference  of  the  ignorant,  it  is  of  undeniable 
value ;  but,  when  it  is  quoted  to  prevent  the  scientific  action  of  the 


PROLONGED  AXD  PRECIPITATE  LABORS.          327 

experienced,  who  know  precisely  when  and  why  to  interfere,  and 
who  have  acquired  the  indispensable  mechanical  skill,  it  is  sadly 
misapplied. 

State  of  the  Uterus  in  Protracted  Labor. — The  nature  of  the  pains 
and  the  state  of  the  uterus,  in  cases  of  protracted  labor,  are  peculiarly 
worthy  of  study,  and  have  been  very  clearly  pointed  out  by  Dr. 
Braxton  Hicks.1  He  shows  that,  when  the  pains  have  apparently 
fallen  off  and  become  few  and  feeble,  or  have  entirely  ceased,  the 
uterus  is  in  a  state  of  continuous  or  tonic  contraction,  and  that  the 
irritation  resulting  from  this  is  the  chief  cause  of  the  more  marked 
symptoms  of  powerless  labor.  If,  in  a  case  of  the  kind,  the  uterus  be 
examined  by  palpation,  it  will  be  found  firmly  contracted  between 
the  pains.  The  correctness  of  this  observation  is  beyond  question, 
and  it  will,  no  doubt,  often  be  an  important  guide  in  treatment. 
Under  such  circumstances  instrumental  interference  is  imperatively 
demanded. 

Conditions  and  Causes  affecting  the  Expulsive  Powers. — In  consider- 
ing the  causes  of  protracted  labor,  it  will  be  well  first  to  discuss  those 
which  affect  the  expulsive  powers  alone,  leaving  those  depending  on 
morbid  states  of  the  passages  for  future  consideration ;  bearing  in 
mind,  however,  that  the  results,  as  regards  both  the  mother  and  the 
child,  are  identical,  whatever  may  be  the  cause  of  delay. 

Constitution  of  the  Patient. — The  general  constitutional  state  of  the 
patient  may  materially  influence  the  force  and  efficiency  of  the  pains. 
Thus  it  not  unfrequently  happens  that  they  are  feeble  and  ineffective 
in  women  of  very  weak  constitution,  or  who  are  much  exhausted  by 
debilitating  disease.  Cazeaux  pointed  out  that  the  effects  of  such 
general  conditions  are  often  more  than  counterbalanced  by  flaccidity 
and  want  of  resistance  of  the  tissues,  so  that  there  is  less  obstacle  to 
the  passage  of  the  child.  Thus  in  phthisical  patients  reduced  to  the 
last  stage  of  exhaustion,  the  labor  is  not  unfrequently  surprisingly 
easy. 

Influence  of  Tropical  Climates. — Long  residence  in  tropical  climates 
causes  uterine  inertia,  in  consequence  of  the  enfeebled  nervous  power 
it  produces.  It  is  a  common  observation  that  European  residents  in 
India  are  peculiarly  apt  to  suffer  from  post-partum  hemorrhage  from 
this  cause.  The  general  mode  of  life  of  patients  has  an  unquestion- 
able effect ;  and  it  is  certain  that  deficient  and  irregular  uterine  action 
is  more  common  in  women  of  the  higher  ranks  of  society,  who  lead 
luxurious,  enervating  lives,  than  in  women  whose  habits  are  of  a 
more  healthy  character. 

Frequent  Child-hearing. — Tyler  Smith  lays  much  stress  on  frequent 
child-bearing  as  a  cause  of  inertia,  pointing  out  that  a  uterus  which 
has  been  very  frequently  subjected  to  the  changes  connected  with 
pregnancy,  is  unlikely  to  be  in  a  typically  normal  condition.  It  is 
doubtful,  however,  whether  the  uterus  of  a  perfectly  healthy  woman 
is  affected  in  this  way ;  certainly,  if  child-bearing  had  undermined 
her  general  health,  the  labors  are  likely  to  be  modified  also. 

1  Obst.  Trans.,  vol.  ix. 


328  LABOR. 

Age  of  Patient. — Age  has  a  decided  effect.  In  the  very  young  the 
pains  are  apt  to  be  irregular,  on  account  of  imperfect  development 
of  the  uterine  muscle.  Labor  taking  place  for  the  first  time  in 
women  advanced  in  life  is  also  apt  to  be  tedious,  but  not  by  any 
means  so  invariably  as  is  generally  believed.  The  apprehensions  of 
such  patients  are  often  agreeably  falsified,  and  where  delay  does 
occur,  it  is  probably  more  often  referable  to  rigidity  and  toughness 
of  the  paturient  passages  than  to  feebleness  of  the  pains. 

Disorders  of  the  Intestines. — Morbid  states  of  the  primae  vise  fre- 
quently cause  irregular,  painful,  and  feeble  contractions.  A  loaded 
state  of  the  rectum  has  often  a  remarkable  influence,  as  evidenced 
by  the  sudden  and  distinct  change  in  the  character  of  the  labor  which 
often  follows  the  use  of  suitable  remedies.  Undue  distension  of  the 
bladder  often  acts  in  the  same  way,  more  especially  in  the  second 
stage.  When  the  urine  has  been  allowed  to  accumulate  unduly,  the 
contraction  of  the  accessory  muscles  of  parturition  often  causes  such 
intense  suffering,  by  compressing  the  distended  viscus,  that  the  pa- 
tient is  absolutely  unable  to  bear  down.  Hence  the  labor  is  carried 
on  by  uterine  contractions  alone,  slowly,  and  at  the  expense  of  much 
suffering.  A  similar  interference  with  the  action  of  the  accessory 
muscles  is  often  produced  by  other  causes.  Thus  if  labor  comes  on 
when  the  patient  is  suffering  from,  bronchitis  or  other  chest  disease, 
she  may  be  quite  unable  to  fix  the  chest  by  a  deep  inspiration,  and 
the  diaphragm,  and  other  accessory  muscles  cannot  act.  In  the  same 
way  they  may  be  prevented  from  acting  when  the  abdomen  is  occu- 
pied by  an  ovarian  tumor,  or  by  ascitic  fluid. 

Mental  conditions  have  a  very  marked  effect.  This  is  so  commonly 
observed  that  it  is  familiar  to  the  merest  beginner  in  midwifery  prac- 
tice. The  fact  that  the  pains  often  diminish  temporarily  on  the 
entrance  of  the  accoucheur  is  known  to  every  nurse ;  and  so  also 
undue  excitement,  the  presence  of  too  many  people  in  the  room, 
over-much  talking,  have  often  the  same  prejudicial  effect.  Depres- 
sion of  mind,  as  in  unmarried  women,  and  fear  and  despondency  in 
women  who  have  looked  forward  with  apprehension  to  their  labor, 
are  also  common  causes  of  irregular  and  defective  action. 

Excessive  Amount  of  Liquor  Amnii. — Undue  distension  of  the  uterus 
from  an  excessive  amount  of  liquor  amnii  not  unfrequently  retards 
the  first  stage,  by  preventing  the  uterus  from  contracting  efficiently. 
When  this  exists,  the  pains  are  feeble  and  have  little  effect  in  dilating 
the  cervix  beyond  a  certain  degree.  This  cause  may  be  suspected, 
when  undue  protraction  of  the  first  stage  is  associated  with  an  unusu- 
ally large  size  and  marked  fluctuation  of  the  uterine  tumor,  through 
which  the  foetal  limbs  cannot  be  made  out  on  palpation.  On  vaginal 
examination,  the  lower  segment  of  the  uterus  will  be  found  to  be 
very  rounded  and  prominent,  while  the  bag  of  membranes  will  not 
bulge  through  the  os  during  the  acme  of  the  pain. 

Malpositions  of  the  Uterus. — A  somewhat  similar  cause  is  undue 
obliquity  of  the  uterus,  which  prevents  the  pains  acting  to  the  best 
mechanical  advantage,  and  often  retards  the  entry  of  the  presenting 
part  into  the  brim.  The  most  common  variety  is  anteversion,  result- 


PROLONGED  AND  PRECIPITATE  LABORS.          329 

ing  from  excessive  laxity  of  the  abdominal  parietes,  which  is  espe- 
cially found  in  women  who  have  borne  many  children.  Sometimes 
this  is  so  excessive  that  the  fundus  lies  over  the  pubis,  and  even 
projects  downwards  towards  the  patient's  knees.  The  consequence 
is  that,  when  labor  sets  in,  unless  corrective  means  be  taken,  the 
pains  force  the  head  against  the  sacrum,  instead  of  directing  it  into 
the  axis  of  the  pelvic  inlet.  Another  common  deviation  is  lateral 
obliquity,  a  certain  degree  of  which  exists  in  almost  all  cases,  but 
sometimes  it  occurs  to  an  excessive  degree.  Either  of  these  states 
can  readily  be  detected  by  palpation  and  vaginal  examination  com- 
bined. In  the  former  the  os  may  be  so  high  up,  and  tilted  so  far 
backwards,  that  it  may  be  at  first  difficult  to  reach  it  at  all. 

Irreyular  and  Spasmodic  Pains. — Besides  being  feeble,  the  uterine 
contractions,  especially  in  the  first  stage,  are  often  irregular  and 
spasmodic,  intensely  painful,  but  producing  little  or  no  effect  on  the 
progress  of  the  labor.  This  kind  of  case  has  been  already  alluded 
to  in  treating  of  the  use  of  anesthetics  (p.  283),  and  is  very  com- 
mon in  highly  nervous  and  emotional  women  of  the  upper  classes. 
Such  irregular  contractions  do  not  necessarily  depend  on  mental 
causes  alone,  and  they  are  often  produced  by  conditions  producing 
irritation,  such  as  loaded  bowels,  too  early  rupture  of  the  membranes, 
and  the  like.  Dr.  Trenholme,  of  Montreal,1  believes  that  such  irregu- 
lar pains  most  frequently  depend  on  abnormal  adhesions  between 
the  decidua  and  the  uterine  walls,  which  interfere  with  the  proper 
dilatation  of  the  os,  and  he  has  related  some  interesting  cases  in 
support  of  this  theory. 

Treatment. — The  mere  enumeration  of  these  various  causes  of  pro- 
tracted labor  will  indicate  the  treatment  required.  Some  of  them, 
such  as  the  constitutional  state  of  the  patient,  age,  or  mental  emotion, 
it  is,  of  course,  beyond  the  power  of  the  practitioner  to  influence  or 
modify ;  but  in  every  case  of  feeble  or  irregular  uterine  action,  a 
careful  investigation  should  be  made  with  the  view  of  seeing  if  any 
removable  cause  exist.  For  example,  the  effect  of  a  large  enema, 
when  we  suspect  the  existence  of  a  loaded  rectum,  is  often  very  re- 
markable ;  the  pains  frequently  almost  immediately  changing  in 
character,  and  a  previously  lingering  labor  being  rapidly  terminated. 

Excessive  distension  of  the  uterus  can  only  be  treated  by  artificial 
evacuation  of  the  liquor  amnii ;  and  after  this  is  done,  the  character 
of  the  pains  often  rapidly  changes.  This  expedient  is  indeed  often 
of  considerable  value  in  cases  in  which  the  cervix  has  dilated  to  a 
certain  extent,  but  in  which  no  further  progress  is  made,  especially 
if  the  bag  of  membranes  does  not  protrude  through  the  os  during 
the  pains,  and  the  cervix  itself  is  soft,  and  apparently  readily  dilata- 
ble. Under  such  circumstances,  rupture  of  the  membranes,  even 
before  the  os  is  fully  dilated,  is  often  very  useful. 

Adherent  Membranes. — If  we  have  reason  to  suspect  morbid  adhe- 
sions between  the  membranes  and  the  uterine  walls,  an  endeavor 
must  be  made  to  separate  them  by  sweeping  the  finger  or  a  flexible 

1  Obst.  Trans.  1873. 
22 


330  LABOR. 

catheter  round  the  internal  margin  of  the  os,  or  puncturing  the  sac. 
The  former  expedient  has  been  advocated  by  Dr.  Inglis;1  as  a  means 
of  increasing  the  pains  when  the  first  stage  is  very  tedious,  and  I 
have  often  practised  it  with  marked  success.  Trenholme's  observa- 
tion affords  a  rationale  of  its  action.  The  manoeuvre  itself  is  easily 
accomplished,  and,  provided  the  os  be  not  very  high  in  the  pelvis, 
does  not  give  any  pain  or  discomfort  to  the  patient. 

Uterine  Deviations. — Attention  should  always  be  paid  to  remedy- 
ing any  deviation  of  the  uterus  from  its  proper  axis.  If  this  be 
lateral,  the  proper  course  to  pursue  is  to  make  the  patient  lie  on  the 
opposite  side  to  that  towards  which  the  organ  is  pointing.  In  the 
more  common  anterior  deviation  she  should  lie  on  her  back,  so  that 
the  uterus  may  gravitate  towards  the  spine,  and  a  firm  abdominal 
bandage  should  be  applied.  This  prevents  the  organ  from  falling 
forwards,  while  its  pressure  stimulates  the  muscular  fibres  to  increased 
action ;  hence  it  is  often  very  serviceable  when  the  pains  are  feeble, 
even  if  there  be  no  anteversion. 

Temporary  Exhaustion. — In  a  frequent  class  of  cases,  especially  in 
the  first  stage,  the  pains  diminish  in  force  and  frequency  from  fatigue, 
and  the  indication  then  is  to  give  a  temporary  rest,  after  which  they 
recommence  with  renewed  vigor.  Hence  an  opiate,  such  as  20 
minims  of  Battley's  solution,  which  often  acts  quickest  when  given 
in  the  form  of  enema,  is  frequently  of  the  greatest  possible  value. 
If  this  secure  a  few  hours'  sleep,  the  patient  will  generally  awake 
much  refreshed  and  invigorated.  It  is  important  to  distinguish  this 
variety  of  arrested  pain  from  that  dependent  on  actual  exhaustion ; 
and  this  can  be  done  by  attention  to  the  general  condition  of  the 
patient,  and  especially  by  observing  that  the  uterus  is  soft  and  flaccid 
in  the  intervals  between  the  pains,  and  that  there  is  none  of  the  tonic 
contraction,  indicated  by  persistent  hardness  of  the  uterine  parietes. 
When  the  pains  are  irregular,  spasmodic,  and  excessively  painful, 
without  producing  any  real  effect,  opiates  are  also  of  great  service ; 
and  it  is  under  such  circumstances  that  chloral  is  especially  valuable. 

Oxytocic  Remedies. — Still  a  large  number  of  cases  will  arise  in 
which  the  absence  of  all  removable  causes  has  been  ascertained,  and 
in  which  the  pains  are  feeble  and  ineffective.  We  must  now  proceed 
to  discuss  their  management.  The  fault  being  the  want  of  sufficient 
contraction,  the  first  indication  is  to  increase  the  force  of  the  pains. 
Here  the  so-called  oxytocic  remedies  come  into  action ;  and,  although 
a  large  number  of  these  have  been  used  from  time  to  time,  such  as 
borax,  cinnamon,2  quinine,  and  galvanism,  practically,  the  only  one 

1  Sydenham  Society's  Year-Book,  1869. 

2  [Quinia  as  an  oxytocic  deserves  more  than  a  passing  notice,  having  been  very 
carefully  tested  by  several  leading  obstetricians  of  Philadelphia  within  a  few  years. 
According  to  the  observations  of  Dr.  Albert  H.  Smith,  in  42  cases  of  parturition,  it 
presents  the  following  peculiar  characteristics. 

It  has  no  power  in  itself  to  excite  uterine  contractions,  but  simply  acts  as  a  general 
stimulant,  and  promoter  of  vital  energy,  and  functional  activity. 

In  normal  labor  at  full  term,  its  administration  in  a  dose  of  fifteen  grains,  is  usually 
followed  in  as  many  minutes  by  a  decided  increase  in  the  force  and  frequency  of  the 


PROLONGED    AND    PRECIPITATE    LABORS.  331 

in  which  any  reliance  is  now  placed  is  the  ergot  of  rye.  This  has 
long  been  the  favorite  remedy  for  deficient  uterine  action,  and  it  is  a 
powerful  stimulant  of  the  uterine  fibres.  It  has,  however,  verv 
serious  disadvantages,  and  it  is  very  questionable  whether  the  risks 
to  both  mother  and.  child  do  not  more  than  counterbalance  any  ad- 
vantages attending  its  use.  The  ergot  is  given  in  doses  of  15  or  20 
grains  of  the  freshly  powdered  drug  diffused  in  warm  water,  or  in 
the  more  convenient  form  of  the  liquid  extract,  in  doses  of  from  20 
to  30  minims.  In  about  fifteen  minutes  after  its  administration  the 
pains  generally  increase  greatly  in  force  and  frequency,  and  if  the 
head  be  low  in  the  pelvis,  and  if  the  soft  parts  offer  no  resistance, 
the  labor  may  be  rapidly  terminated. 

Objections  to  its  Use. — Were  its  use  always  followed  by  this  effect 
there  would  be  little  or  no  objection  to  its  administration.  The  pains, 
however,  are  different  from  those  of  natural  labor,  being  strong,  per- 
sistent, and  constant.  Its  effect,  indeed,  is  to  produce  that  very  state 
of  tonic  and  persistent  uterine  contraction,  which  has  been  already 
pointed  out  as  one  of  the  chief  dangers  of  protracted  labor.  Hence 
if,  from  any  cause,  the  exhibition  of  the  drug  be  not  followed  by  rapid 
delivery,  a  condition  is  produced  which  is  serious  to  the  mother  ; 
and  which  is  extremely  perilous  to  the  child,  on  account  of  the  tonic 
contraction  of  the  muscular  fibres  obstructing  the  utero-placental 
circulation.  Dr.  Hardy  found  that  soon  the  foetal  pulsations  fall  to 
100,  and,  if  delivery  be  long  delayed,  they  commence  to  intermit. 
He  also  observed  that  when  this  occurred  the  child  was  always  born 
dead,  and  found  that  the  number  of  still-born  children  after  ergot 
has  been  exhibited  was  very  large ;  for  out  of  30  cases  in  which  he 
gave  it  in  tedious  labor,  only  10  of  the  children  were  born  alive. 
Nor  is  its  use  by  any  means  free  from  danger  to  the  mother  ;  a  not 
inconsiderable  number  of  cases  of  rupture  of  the  uterus  have  been 
attributed  to  its  incautious  use.  Hence,  if  it  is  to  be  given  at  all,  it 
is  obvious  that  it  must  be  with  strict  limitations,  and  after  careful 
consideration. 

Limitations  to  its  Use. — The  cardinal  point  to  remember  is  that  it 
is  absolutely  contra-indicated  unless  the  absence  of  all  obstacles  to 
rapid  delivery  has  been  ascertained.1  Hence,  it  is  only  allowable 
when  the  first  stage  is  over,  and  the  os  fully  dilated ;  when  the  ex- 
perience of  former  labors  has  proved  the  pelvis  to  be  of  ample  size ; 
and  when  the  perineum  is  soft  and  dilatable.  Perhaps,  as  has  been 

uterine  contractions,  changing  in  some  instances  a  tedious  exhausting  labor,  into  one 
of  rapid  energy,  advancing  to  an  early  completion. 

It  promotes  the  permanent  tonic  contraction  of  the  uterus,  after  the  expulsion  of 
the  placenta;  women  that  had  flooded  in  former  labors,  escaping  entirely,  there  not 
having  been  an  instance  of  post-partum  hemorrhage  in  the  whole  42  cases, 

It  also  diminishes  the  lochial  How  where  it  had  been  excessive  in  former  labors,  the 
change  being  remarked  upon  by  the  patients  ;  and  consequently  lessens  the  severity 
of  the  after-pains. 

Cinchonism  is  very  rarely  observed  as  an  effect  of  large  doses  in  parturient  women. — 
ED.— Trans.  Coll.  Phys.  Phila.  1875,  p.  183.] 

'  [We  cannot  be  too  cautious  in  using,  or  recommending  the  use  of  ergot.  For- 
tunately we  can  accomplish  much  with  the  use  of  quinia.  See  page  330. — En.] 


332  LABOR. 

suggested,  the  administration  of  small  doses  of  from  5  to  10  minims 
of  the  liquid  extract  every  ten  minutes,  until  more  energetic  action 
set  in,  might  obviate  some  of  these  risks. 

Manual  Pressure  as  a  Means  of  Increasing  the  Uterine  Contractions. 
— If  we  had  no  other  means  of  increasing  defective  uterine  contrac- 
tions at  our  disposal,  and  if  the  choice  lay  only  between  the  use  of 
ergot  and  instrumental  delivery,  there  might  not  be  so  much  objec- 
tion to  a  cautious  use  of  the  drug  in  suitable  cases.  We  have,  how- 
ever, a  means  of  increasing  the  force  of  the  uterine  contractions  so  much 
more  manageable,  and  so  much  more  resembling  the  natural  process, 
that  I  believe  it  to  be  destined  to  entirely  supersede  the  administration 
of  ergot.  This  is  the  application  of  manual  pressure  to  the  uterus 
through  the  abdomen,  an  expedient  that  has  of  late  years  been  much 
used  in  Germany,  and  has  begun  to  be  employed  in  English  practice. 
I  believe,  therefore,  that  ergot  should  be  chiefly  used  for  the  purpose 
of  exciting  uterine  contraction  after  delivery,  when  its  peculiar 
property  of  promoting  tonic  contraction  is  so  valuable,  and  that  it 
should  rarely,  if  at  all,  be  employed  before  the  birth  of  the  child. 

The  systematic  use  of  uterine  pressure  as  an  oxytocic  was  first 
prominently  brought  under  the  notice  of  the  profession  by  Kristeller, 
under  the  name  of  "  Expressio  Foatus,"  although  it  has  been  used  in 
various  forms  from  time  immemorial.  Albucasis,  for  example,  was 
clearly  acquainted  with  its  use,  and  referred  to  it  in  the  following 
terms :  "  Cum  ergo  vides  ista  signa,  tune  oportet,  ut  comprimatur 
uterus  ejus  ut  descendat  embryo  velociter."  There  are  some  curious 
obstetric  customs  among  various  nations,  which  probably  arose  from 
a  recognition  of  its  value ;  as,  for  example,  the  mode  of  delivery 
adopted  among  the  Kalmucks,  where  the  patient  sits  at  the  foot  of 
the  bed,  while  a  woman,  seated  behind  her,  seizes  her  round  the  waist 
and  squeezes  the  uterus  during  the  pains.  Amongst  the  Japanese, 
Siamese,  North  American  Indians,  and  many  other  nations,  pressure, 
applied  in  various  ways,  is  habitually  used. 

Kristeller  maintains  that  it  is  possible  to  effect  the  complete  ex- 
pulsion of  the  child  by  properly  applied  pressure,  even  when  the 
pains  are  entirely  absent.  Strange  as  this  may  appear  to  those  who 
are  not  familiar  with  the  effects  of  pressure,  I  believe  that,  under 
exceptional  circumstance,  when  the  pelvis  is  very  capacious,  and  the 
soft  parts  offer  but  slight  resistance,  it  can  be  done.  I  have  delivered 
in  this  way  a  patient  whose  friends  would  not  permit  me  to  apply 
the  forceps,  when  I  could  not  recognize  the  existence  of  any  uterine 
contraction  at  all,  the  foetus  being  literally  squeezed  out  of  the  uterus. 
It  is  not,  however,  as  replacing  absent  pains,  but  as  a  means  of  in- 
tensifying and  prolonging  the  effects  of  deficient  and  feeble  ones,  that 
pressure  finds  its  best  application. 

Its  effects  are  often  very  remarkable,  especially  in  women  of  slight 
build,  where  there  is  but  little  adipose  tissue  in  the  abdominal  walls, 
and  not  much  resistance  in  the  pelvic  tissues.  If  the  finger  be  placed 
on  the  head  while  pressure  is  applied  to  the  uterus,  a  very  marked 
descent  can  readily  be  felt,  and  not  infrequently  two  or  three  appli- 
cations will  force  the  head  on  to  the  perineum.  There  are,  however, 


PROLONGED    AND    PRECIPITATE    LABORS.  333 

certain  conditions  when  it  is  inapplicable,  and  the  existence  of  which 
should  centra-indicate  its  use.  Thus  if  the  uterus  seem  unusually 
tender  on  pressure,  and,  a  fortiori,  if  the  tonic  contraction  of  ex- 
haustion he  present,  it  is  inadmissible.  So  also  if  there  be  any  ob- 
struction to  rapid  delivery,  either  from  narrowing  of  the  pelvis  or 
rigidity  of  the  soft  parts,  it  should  not  be  used.  The  cases  suitable 
for  its  application  are  those  in  which  the  head  or  breech  is  in  the 
pelvic  cavity,  and  the  delay  is  simply  due  to  a  want  of  sufficiently 
strong  expulsive  action. 

Mode  of  Application. — -It  may  be  applied  in  two  ways.  The  better 
is  to  place  the  patient  on  her  back  at  the  edge  of  the  bed,  and  spread 
the  palms  of  the  hands  on  either  side  of  the  fundus  and  body  of  the 
uterus,  and,  when  a  pain  commences,  to  make  firm  pressure  during 
its  continuance  downwards  and  backwards  in  the  direction  of  the 
pelvic  inlet.  As  the  contraction  passes  off  the  pressure  is  relaxed, 
and  again  resumed  when  a  fresh  pain  begins.  In  this  way  each  pain 
is  greatly  intensified,  and  its  effect  on  the  progress  of  the  foetus  much 
increased.  It  is  not  essential  that  the  patient  should  lie  on  her  back. 
A  useful,  although  not  so  great,  amount  of  pressure  can  be  applied 
when  she  is  lying  in  the  ordinary  obstetric  position  on  her  left  side, 
the  left  hand  being  spread  out  over  the  fundus,  leaving  the  right  free 
to  watch  the  progress  of  the  presenting  part  per  vaginam. 

Special  Value  of  Uterine  Pressure. — The  special  value  of  this 
method  of  treating  ineffective  pains  is,  that  the  amount  and  fre- 
quency of  the  pressure  are  completely  within  the  control  of  the 
practitioner,  and  are  capable  of  being  regulated  to  a  nicety  in  ac- 
cordance with  the  requirements  of  each  particular  case.  It  has  the 
peculiar  advantage  of  closely  imitating  the  natural  means  of  delivery, 
and  of  being  absolutely  without  risk  to  the  child :  nor  is  there  any 
reason  to  think  that  it  is  capable  of  injuring  the  mother.  At  least  I 
may  safely  say  that,  out  of  the  large  number  of  cases  in  which  I 
have  used  it,  I  have  never  seen  one  in  which  I  had  the  least  reason 
to  think  that  it  had  proved  hurtful.  Of  course,  it  is  essential  not  to 
use  undue  roughness :  firm  and  even  strong  pressure  may  be  em- 
ployed, but  that  can  be  done  without  being  rough ;  and,  as  its  appli- 
cation is  always  intermittent,  there  is  no  time  for  it  to  inflict  any 
injury  on  the  uterine  tissues. 

Pressure  is  specially  valuable  when  it  is  desirable  to  intensify 
feeble  pains.  It  may  be  serviceably  employed  when  the  pains  are 
altogether  absent,  to  imitate  and  replace  them,  provided  there  be 
nothing  but  the' absence  of  a  vis  a  tergo  to  prevent  speedy  delivery. 
In  such  cases  an  endeavor  should  be  made  to  imitate  the  pains  as 
closely  as  possible,  by  applying  the  pressure  at  intervals  of  four  or 
five  minutes,  and  entirely  relaxing  it  after  it  has  been  applied  for  a 
few  seconds. 

Change  of  Professional  Opinion  as  to  Instrumental  Delivery. — 
When  all  these  means  fail  we  have  then  left  the  resource  of  instru- 
mental aid,  and  we  have  now  to  consider  the  indications  for  the  use 
of  the  forceps  under  such  circumstances.  It  has  been  already  pointed 


334  LABOR. 

out  that  professional  opinion  on  this  point  lias  been  undergoing  a 
marked  change ;  and  that  it  is  now  recognized  as  an  axiom  by  the 
most  experienced  teachers  that,  when  we  are  once  convinced  that  the 
natural  efforts  are  failing,  and  are  unlikely  to  effect  delivery,  except 
at  the  cost  of  long  delay,  it  is  far  better  to  interfere  soon  rather  than 
late,  and  thus  prevent  the  occurrence  of  the  serious  symptoms  ac- 
companying protracted  labor.  This  is,  of  course,  a  practice  directly 
opposed  to  that  so  long  taught  in  our  standard  works,  in  which  in- 
strumental interference  was  strictly  prohibited  unless  all  hope  of 
natural  delivery  was  at  end ;  and  in  which  the  commencement  at 
least,  if  not  the  complete  establishment,  of  symptoms  of  exhaustion, 
was  considered  to  be  the  only  justification  for  the  application  of  for- 
ceps in  lingering  labor. 

Views  of  Dr.  Johnston  on  the  Use  of  the  Forceps. — The  reasons  which 
have  led  the  late  distinguished  Master  of  the  Rotunda  Hospital  to  a 
more  frequent  use  of  the  forceps  are  so  well  expressed  in  his  report 
for  1872,  that  I  venture  to  quote  them,  as  the  best  justification  for  a 
practice  that  many  practitioners  of  the  older  school  will,  no  doubt, 
be  inclined  to  condemn  as  rash  and  hazardous.  He  says:1  "Our 
established  rule  is  that  so  long  as  nature  is  able  to  effect  its  purpose 
without  prejudice  to  the  constitution  of  the  patient,  danger  to  the 
soft  parts,  or  the  life  of  the  child,  we  are  in  duty  bound  to  allow  the 
labor  to  proceed ;  but  as  soon  as  we  find  the  natural  efforts  are  be- 
ginning to  fail,  and  after  having  tried  the  milder  means  for  relaxing 
the  parts  or  stimulating  the  uterus  to  increased  action,  and  the  de- 
sired effects  not  being  produced,  we  consider  we  are  in  duty  bound 
to  adopt  still  prompter  measures,  and  by  our  timely  assistance  relieve 
the  sufferer  from  her  distress  and  her  offspring  from  an  imminent 
death.  Why,  may  I  ask,  should  we  permit  a  fellow  creature  to 
undergo  hours  of  torture  when  \ve  have  the  means  of  relieving  them 
within  our  reach  ?  Why  should  she  be  allowed  to  waste  her  strength, 
and  incur  the  risks  consequent  upon  long  pressure  of  the  head  on  the 
soft  parts,  the  tendency  to  inflammation  and  sloughing,  or  the  danger 
of  rupture,  not  to  speak  of  the  poisonous  miasm  which  emanates 
from  an  inflammatory  state  of  the  passages,  the  result  of  tedious 
labor,  and  which  is  one  of  the  fertile  causes  of  puerperal  fever  and 
all  its  direful  effects/attributed  by  some  to  the  influence  of  being 
confined  in  a  large  maternity,  and  not  to  its  proper  source,  i.  e.,  the 
labor  being  allowed  to  continue  till  inflammatory  symptoms  appear. 
The  more  we  consider  the  benefits  of  timely  interference,  and  the 
good  results  which  follow  it,  the  more  are  we  induced  to  pursue  the 
system  we  have  adopted,  and  to  inculcate  to  those  we  are  instructing 
the  advantages  to  be  gained  by  such  practice,  both  in  saving  the  life 
of  the  child  as  well  as  securing  the  greater  safety  of  the  mother." 
It  would  be  impossible  to  put  the  matter  in  a  stronger  or  clearer 
light,  and  I  feel  confident  that  these  views  will  be  endorsed  by  all 
who  have  adopted  the  more  modern  practice. 

1  Fourth  Clinical  Report  of  the  Rotunda  Lying-in  Hospital  for  the  year  ending 
1872. 


PROLONGED  AND  PRECIPITATE  LABORS.          835 

Effect  of  Early  Interference  on  the  Infantile  Mortality. — In  the  first 
edition  of  this  work  I  used  the  statistics  of  Dr.  Hamilton,  of  Falkirk, 
and  other  modern  writers,  as  proving  that  a  more  frequent  use  of  the 
forceps  than  has  been  customary,  diminished  in  a  remarkable  degree 
the  infantile  mortality.  Dr.  Galabin1  has  recently  published  an  ad- 
mirable paper  on  this  subject,  in  which,  by  a  careful  criticism  of 
these  figures,  he  lias,  I  think,  proved  that  the  conclusions  drawn  from 
them  are  open  to  doubt,  and  that  the  saving  of  infantile  life  follow- 
ing more  frequent  forceps  delivery  is  by  no  means  so  great  as  I  had 
supposed.  This,  however,  does  not  in  any  way  touch  the  main  points 
at  issue  referred  to  in  the  preceding  paragraph. 

Possible  Dangers  Attending  the  Use  of  the  Forceps. — It  is,  of  course, 
right  that  we  should  consider  the  opposite  point  of  view,  and  reflect 
on  the  disadvantages  which  may  attend  the  interference  advocated. 
Here  I  should  point  out  that  I  am  now  talking  only  of  the  use  of  the 
forceps  in  simple  inertia,  when  the  head  is  low  in  the  pelvic  cavity, 
and  when  all  that  is  wanted  is  a  slight  v is  a  fronte  to  supplement 
the  deficient  vis  a  tergo.  The  use  of  the  instrument  when  the  head 
is  arrested  high  in  the  pelvis,  or  in  cases  of  deformity,  or  before  the 
os  uteri  is  completely  expanded,  is  an  entirely  different  and  much 
more  serious  matter,  and  does  not  enter  into  the  present  discussion. 
The  chief  question  to  decide  is  if  there  be  sufficient  risk  to  the  mother 
to  counterbalance  that  of  delay.  It  will,  of  course,  be  conceded  by 
all,  that  the  forceps  in  the  hands  of  a  coarse,  bungling,  and  ignorant 
practitioner,  who  has  not  studied  the  proper  mode  of  operating,  may 
easily  inflict  serious  damage.  The  possibility  of  inflicting  injury  in 
this  way  should  act  as  a  warning  to  every  obstetrician  to  make  him- 
self thoroughly  acquainted  with  the  proper  mode  of  using  the  instru- 
ment, and  to  acquire  the  manual  skill  which  practice  and  the  study 
of  the  mechanism  of  delivery  will  alone  give ;  but  it  can  hardly  be 
used  as  an  argument  against  its  use.  If  that  were  admitted,  surgical 
interference  of  any  kind  would  be  tabooed,  since  there  is  none  that 
ignorance  and  incapacity  might  not  render  dangerous. 

Assuming,  therefore,  that  the  practitioner  is  able  to  apply  the  for- 
ceps skilfully,  is  there  any  inherent  danger  in  its  use  ?  I  think  all 
who  dispassionately  consider  the  question  must  admit  that,  in  the 
class  of  cases  alluded  to,  the  operation  is  so  simple  that  its  disad- 
vantages cannot  for  a  moment  be  weighed  against  those  attending 
protraction  and  its  consequences.  Against  this  conclusion  statistics 
may  possibly  be  quoted,  such  as  those  of  Churchill,  who  estimated 
that  1  in  20  mothers  delivered  by  forceps  in  British  practice  were 
lost.  But  the  fallacy  of  such  figures  is  apparent  on  the  slightest 
consideration ;  and  by  no  one  has  this  been  more  conclusively  shown 
than  by  Drs.  Hicks  and  Phillips  in  their  paper  on  tables  of  mortality 
after  obstetric  operations,2  where  it  is  proved  in  the  clearest  manner 
that  such  results  are  due  not  to  the  treatment,  but  rather  to  the  fact 
that  the  treatment  was  so  long  delayed. 

1  Obstetrical  Journal,  December,  1877. 

2  Obst.  Trans,  vol.  xiii. 


336  LABOR. 

Impossibility  of  giving  Definite  Rules  for  use  of  Forceps. — It  is 
quite  impossible  to  lay  clown  any  precise  rule  as  to  when  the  forceps 
should  be  used  in  uterine  inertia.  Each  case  must  be  treated  on  its 
own  merits,  and  after  a  careful  estimate  of  the  eft'ect  of  the  pains. 
The  rules  generally  taught  were,  that  the  head  should  be  allowed  to 
rest  at  or  near  the  perineum  for  a  number  of  hours,  and  that  inter- 
ference was  contra-indicated  if  the  slightest  progress  were  being 
made.  It  is  needless  to  say  that  both  of  these  rules  are  incompatible 
with  the  views  I  have  been  inculcating,  and  that  any  rule  based  upon 
the  length  of  time  the  second  stage  of  labor  has  lasted  must  neces- 
sarily be  misleading.  What  has  to  be  done,  I  conceive,  is  to  watch 
the  progress  of  the  case  anxiously  after  the  second  stage  has  fairly 
commenced,  and  to  be  guided  by  an  estimate  of  the  advance  that  is 
being  made  and  the  character  of  the  pains,  bearing  in  mind  that  the 
risk  to  the  mother,  and  still  more  to  the  child,  increases  seriously 
with  each  hour  that  elapses.  If  we  find  the  progress  slow  and  un- 
satisfactory, the  pains  flagging  and  insufficient,  and  incapable  of 
being  intensified  by  the  means  indicated,  then,  provided  the  head  be 
low  in  the  pelvis,  it  is  better  to  assist  at  once  by  the  forceps,  rather 
than  to  wait  until  we  are  driven  to  do  so  by  the  state  of  the  pa- 
tient.1 

1  It  may,  perhaps,  be  of  interest  in  connection  with  this  important  topic  in  prac- 
tical midwifery,  if  I  reprint  a  letter  I  published  some  years  ago  in  the  Medical  Times 
and  Gazette.  An  historical  case,  such  as  that  of  which  it  treats,  will  better  illus- 
trate the  evil  effects  that  may  follow  unnecessary  delay  than  any  amount  of  argument. 
It  seems  to  me  impossible  to  read  the  details  of  the  delivery  it  describes  without 
being  forcibly  struck  with  the  disastrous  results  which  followed  the  practice  adopted, 
which,  however,  was  strictly  in  accordance  with  that  which,  up  to  a  quite  recent  date, 
has  been  considered  correct  by  the  highest  obstetric  authorities. 

ON  THE  DEATH  OF  THE  PRINCESS  CHARLOTTE  OF  WALES. 

(To  the  Editor  of  the  Medical  Times  and  Gitttte.) 

SIR:  The  letter  of  your  correspondent,  "An  Old  Accoucheur,"  regarding  the 
death  of  the  Princess  Charlotte,  raises  a  question  of  great  interest — viz.,  whether 
the  fatal  result  might  have  been  averted  under  other  treatment  ?  The  history  of  the 
case  is  most  instructive,  and  I  think  a  careful  consideration  of  it  leaves  little  room  to 
doubt  that,  though  the  management  of  the  labor  was  quite  in  accordance  with  the 
teaching  of  the  day,  it  was  entirely  opposed  to  that  of  modern  obstetric  science. 
The  following  account  of  the  labor  may  interest  your  readers  and  will  probably  be 
new  to  most  of  them.  It  is  contained  in  a  letter  from  Dr.  John  Sims  to  the  late  Dr. 
Joseph  Clarke,  of  Dublin: — 

London,  November  15,  1817. 

"  My  Dear  Sir. — I  do  not  wonder  at  your  wishing  to  have  a  correct  statement  of 
the  labor  of  her  Royal  Highness  the  Princess  Charlotte,  the  fatal  issue  of  which  has 
involved  the  whole  nation  in  distress.  You  must  excuse  my  being  very  concise,  as  I 
have  been  and  am  very  much  hurried.  I  take  the  opportunity  of  writing  this  in  a 
lying-in  chamber.  Her  Royal  Highness's  labor  commenced  by  the  discharge  of  the 
liquor  amnii  about  seven  o'clock  on  Monday  evening,  and  the  pains  followed  soon 
after.  They  continued  through  the  night  and  a  great  part  of  the  next  day — sharp, 
soft,  but  very  ineffectual.  Towards  the  evening  Sir  Richard  Croft  began  to  suspect 
that  labor  might  not  terminate  without  artificial  assistance,  and  a  message  was  de- 
spatched for  me.  I  arrived  at  two  on  Wednesday  morning.  The  labor  was  now 
advancing  more  favorably,  and  both  Dr.  Baillie  and  myself  concurred  in  the  opinion 


PROLONGED    AND    PRECIPITATE    LABORS.  337 

Precipitate  Labor  less  common  than  Lingering. — Undue  rapidity  of 
labor  is  certainly  more  uncommon  than  its  converse,  but  still  it  is  by 

that  it  would  not  be  advisable  to  inform  her  Royal  Highness  of  my  arrival.  From 
this  time  to  the  end  of  her  labor  the  progress  was  uniform,  though  very  slow,  the 
patient  in  good  spirits,  the  pulse  calm,  and  there  never  was  room  to  entertain  a  ques- 
tion about  the  use  of  instruments.  About  six  in  the  afternoon  the  discharge  became 
of  a  green  eolor,  which  led  to  a  suspicion  that  the  child  might  be  dead ;  still  the 
giving  assistance  was  quite  out  of  the  question,  as  the  pains  now  became  more 
effectual,  and  the  labor  proceeded  regularly  though  slowly.  The  child  was  born 
without  artificial  assistance  at  nine  o'clock  in  the  evening.  Attempts  were  made  for 
a  good  while  to  reanimate  it  by  inflating  the  lungs,  friction,  hot  baths,  etc.,  but  with- 
out effect ;  the  heart  could  not  be  made  to  beat  even  once.  Soon  after  delivery  Sir 
Richard  Croft  discovered  that  the  xiterus  was  contracted  in  the  middle  in  the  hour- 
glass form,  and  as  some  hemorrhage  commenced  it  was  agreed  that  the  placenta 
should  be  brought  away  by  introducing  the  hand.  This  was  done  about  half  an  hour 
after  the  delivery  of  the  child  with  more  ease  and  less  loss  of  blood  than  usual.  Her 
Royal  Highness  continued  well  for  about  two  hours  ;  she  then  complained  of  being 
sick  at  stomach,  and  of  noise  in  the  ears,  began  to  be  talkative,  and  her  pulse  became 
frequent ;  but  I  understand  she  was  very  quiet  after  this,  and  her  pulse  calm.  About 
half- past  twelve  o'clock  she  complained  of  severe  pain  in  her  chest,  became  ex- 
tremely restless,  with  rapid,  weak,  and  irregular  pulse.  At  this  time  I  saw  her  i'or 
the  first  time.  It  has  been  said  that  we  had  all  gone  to  bed,  but  that  is  not  a  fact ; 
Croft  did  not  leave  her  room,  Baillie  retired  about  eleven,  and  I  went  to  my  bed- 
chamber and  laid  down  in  my  clothes  at  twelve.  By  dissection,  some  bloody  fluid 
(two  ounces)  was  found  in  the  pericardium,  supposed  to  be  thrown  out  in  articulo 
mortis.  The  brain  and  other  organs  all  sound,  except  the  right  ovarium,  which  was 
distended  into  a  cyst  the  size  of  a  hen's  egg.  The  hour-glass  contraction  of  the 
uterus  still  visible,  and  a  considerable  quantity  of  blood  in  the  cavity  of  the  uterus — 
but  those  present  dispute  about  the  quantity,  so  much  as  from  twelve  ounces  to  a 
pound  and  a  half — her  uterus  extending  as  high  as  her  navel.  The  cause  of  her 
Royal  Highness's  death  is  certainly  somewhat  obscure  :  the  symptoms  were  such  as 
attend  death  from  hemorrhage,  but  the  loss  of  blood  did  not  seem  to  be  sufficient  to 
account  for  a  fatal  issue.  It  is  possible  that  the  effusion  into  the  pericardium  took 
place  earlier  than  was  supposed,  and  it  does  not  seem  to  be  quite  certain  that  this 
might  not  be  the  cause.  That  I  did  not  see  her  Royal  Highness  more  early  was 
awkward,  and  it  would  have  been  better  that  I  had  been  introduced  before  the  labor 
was  expected  ;  and  it  should  have  been  understood  that  when  labor  came  on  I  should 
be  sent  to  without  waiting  to  know  whether  a  consultation  was  necessary  or  not.  I 
thought  so  at  the  time,  but  I  could  not  propose  such  an  arrangement  to  Croft.  But 
this  is  entirely  entre  nous.  I  am  glad  to  hear  that  your  son  is  well,  and,  with  all  my 
family,  wish  to  be  remembered  to  him.  We  were  happy  to  hear  that  he  was  agree- 
ably married.  "I  remain,  my  dear  Doctor, 

"  Ever  yours  most  truly, 

"JOHN  SIMS,  M.I). 

"  This  letter  is  confidential,  as  perhaps  I  might  be  blamed  for  writing  any  particu- 
lars without  the  permission  of  Prince  Leopold." 

What  are  the  facts  here  shown  ?  Here  was  a  delicate  young  woman  prepared  for 
the  trial  before  her,  as  Baron  Stockmar  tells  us,  by  "lowering  the  organic  strength 
of  the  mother  by  bleeding,  aperients,  and  low  diet,"  who  was  allowed  to  go  on  in 
lingering  feeble  labor  for  no  less  than  fifty-two  hours  after  the  escape  of  the  liquor 
amnii !  Such  was  the  groundless  dread  of  instrumental  interference  then  prevalent 
that,  although  the  case  dragged  on  its  weary  length  with  feeble  ineffectual  pains, 
every  now  and  then  increasing  a  little  in  intensity  and  then  falling  off  again,  it  is 
stated  "there  never  was  room  to  entertain  a  question  about  the  use  of  instruments ;  " 
and  even  "  when  the  discharge  became  of  a  green  color  .  .  .  still  the  giving  assist 
ance  was  quite  out  of  the  question  !"  Can  any  reasonable  man  doubt  that  if  the 
forceps  had  been  employed  hours  and  hours  before — say  on  Tuesday,  when  the  pains 
fell  off — the  result  would  probably  have  been  very  different,  and  that  the  life  of  the 
child,  destroyed  by  the  enormously  prolonged  second  stage,  would  have  been  saved  ? 


338  LABOR. 

no  means  of  unfrcquent  occurrence.  Most  obstetric  works  contain  a 
formidable  catalogue  of  evils  that  may  attend  it,  such  as  rupture  of 
the  cervix,  or  even  of  the  uterus  itself,  from  the  violence  of  the 
uterine  action ;  laceration  of  the  perineum  from  the  presenting  part 
being  driven  through  before  dilatation  has  occurred ;  fainting  from 
the  sudden  emptying  of  the  uterus ;  hemorrhage  from  the  same 
cause.  With  regard  to  the  child  it  is  held  that  the  pressure  to  which 
it  is  subjected,  and  sudden  expulsion  while  the  mother  is  in  the  erect 
position,  may  prove  injurious.  Without  denying  that  these  results 
may  possibly  occur  now  and  again,  in  the  majority  of  cases  over- 
rapid  labor  is  not  attended  with  any  evil  effects. 

Precipitate  labor  may  generally  be  traced  to  one  of  two  conditions, 
or -to  a  combination  of  both;  excessive  force  and  rapidity  of  the 
pains,  or  unusual  laxity  and  want  of  resistance  of  the  soft  parts. 
The  precise  causes  inducing  these  it  is  difficult  to  estimate.  In  some 
cases  the  former  may  depend  on  an  undue  amount  of  nervous  ex- 
citability, and  the  latter  on  the  constitutional  state  of  the  patient 
tending  to  relaxation  of  the  tissues. 

Whatever  the  cause,  the  extreme  rapidity  of  labor  is  occasionally 
remarkable,  and  one  strong  pain  may  be  sufficient  to  effect  the  ex- 
pulsion of  the  child,  with  little  or  no  preliminary  warning.1  I  have 
known  a  child  to  be  expelled  into  the  pan  of  a  water-closet,  the  only 
previous  indication  of  commencing  labor  being  a  slight  griping  pain, 

It  must  be  remembered  that  early  on  Tuesday  morning  delivery  was  expected,  so 
that  the  head  must  then  have  been  low  in  the  pelvis  {vide  Stockmar's  "Memoirs," 
vol.  i.  p.  63).  It  would  be  difficult  to  find  a  case  which  more  forcibly  illustrates  the 
danger  of  delay  in  the  second  stage  of  labor.  Then  what  follows  ?  The  uterus, 
exhausted  by  the  lengthy  efforts  it  should  have  been  spared,  fails  to  contract  effect- 
ually ;  nor  do  we  hear  of  any  attempts  to  produce  contraction  by  pressure.  The 
relaxed  organ  becomes  full  of  clots,  extending  up  to  the  umbilicus,  and  all  the  most 
characteristic  symptoms  of  concealed  post-partum  hemorrhage  develop  themselves. 
She  complained  "of  being  sick  at  stomach,  and  of  noise  in  her  ears — began  to  be 
talkative,  and  her  pulse  became  frequent."  Before  long  other  symptoms  came  on, 
graphically  described  by  Baron  Stockmar,  and  which  seem  to  point  to  the  formation 
of  a  clot  in  the  heart  and  pulmonary  arteries — a  most  likely  occurrence  after  such  a 
history.  "  Baillie  sent  me  word  that  he  wished  me  to  see  the  Princess.  I  hesitated, 
but  at  last  went  with  him.  She  was  suffering  from  spasms  of  the  chest  and  difficulty 
of  breathing,  in  great  pain,  and  very  restless,  and  threw  herself  continually  from  one 
side  of  the  bed  to  the  other,  speaking  now  to  Baillie,  now  to  Croft.  Baillie  said  to 
her — '  Here  comes  an  old  friend  of  yours.'  She  held  out  her  left  hand  to  me 
hastily,  and  pressed  mine  warmly  twice.  I  felt  her  pulse  ;  it  was  going  very  fast — 
the  beats  now  strong,  now  feeble,  now  intermittent." 

Here  was  evidently  something  different  from  the  exhaustion  of  hemorrhage  ;  and 
no  one  who  has  witnessed  a  case  of  pulmonary  obstruction  can  fail  to  recognize  in 
this  account  an  accurate  delineation  of  its  dreadful  symptoms. 

Surely  this  lamentable  story  can  only  lead  to  the  conclusion  that  the  unhappy  and 
gifted  Princess  fell  a  victim  to  the  dread  of  that  bugbear,  "  meddlesome  midwifery," 
which  has  so  long  retarded  the  progress  of  obstetrics. 

I  am,  etc.,  W.  S.  PLAYFAIU. 

Curzon-street,  Mayfair,  W.,  November  29,  1872. 

1  [In  two  cases  seen  by  the  editor,  a  spinal  affection  perverted,  or  diminished  the 
natural  feelings  of  the  pelvic  organs,  and  induced  a  belief  that  defecation  was  immi- 
nent. Where  the  dropped  child  is  illegitimate  and  dead,  it  may  bring  the  mother 
under  suspicion  of  infanticide. — ED.] 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS,     339 

which  led  the  mother  to  fancy  that  an  action  of  the  bowels  was  about 
to  take  place.  More  often  there  is  what  may  be  described  as  a  storm 
of  uterine  contractions,  one  pain  following  the  other  with  great  in- 
tensity, until  the  foetus  is  expelled.  The  natural  effect  of  this  is  to 
produce  a  great  amount  of  alarm  or  nervous  excitement,  which  of 
itself  forms  one  of  the  worst  results  of  this  class  of  labor.  It  is 
under  such  circumstances  that  temporary  mania  occurs,  produced  by 
the  intensity  of  the  suffering,  under  which  the  patient  may  commit 
acts  her  responsibility  for  which  may  fairly  be  open  to  question. 

Treatment.- — -Little  can  be  done  in  treating  undue  rapidity  of  labor. 
We  can,  to  some  extent,  modify  the  intensity  of  the  pains  by  urging 
the  patient  to  refrain  from  voluntary  efforts,  and  to  open  the  glottis 
by  crying  out,  so  that  the  chest  may  no  longer  be  a  fixed  point  for 
muscular  action.  Opiates  have  been  advised  to  control  uterine 
action,  but  it  is  needless  to  point  out  that,  in  most  cases,  there  is  no 
time  for  them  to  take  effect.  Chloroform  will  often  be  found  most 
valuable,  from  the  rapidity  with  which  it  can  be  exhibited ;  and  its 
power  of  diminishing  uterine  action,  which  forms  one  of  its  chief 
drawbacks  in  ordinary  practice,  will  here  prove  of  much  service. 


CHAPTER  X. 

LABOE   OBSTRUCTED   BY   FAULTY   CONDITION   OF    THE    SOFT   PARTS. 

Rigidity  of  the  Cervix  a  frequent  Cause  of  Protracted  Labor. — One 
of  the  most  frequent  causes  of  delay  in  the  first  stage  of  labor  is 
rigidity  of  the  cervix  uteri,  which  may  depend  on  a  variety  of  con- 
ditions. It  is  often  produced  by  premature  escape  of  the  liquor 
amnii,  in  consequence  of  which  the  fluid  wedge,  which  is  nature's 
means  of  dilating  the  os,  is  destroyed  and  the  hard  presenting  part 
is  consequently  brought  to  bear  directly  upon  the  tissues  of  the  cer- 
vix, which  are  thus  unduly  irritated,  and  thrown  into  a  state  of 
spasmodic  contraction.  At  other  times  it  may  be  due  to  consti- 
tutional peculiarities,  among  which  there  is  none  so  common  as  a 
highly  nervous  and  emotional  temperament,  which  renders  the  patient 
peculiarly  sensitive  to  her  sufferings,  and  interferes  with  the  har- 
monious action  of  the  uterine  fibres.  The  pains,  in  such  cases,  cause 
intense  agony,  are  short  and  cramp-like  in  character,  but  have  little 
or  no  effect  in  producing  dilatation  ;  the  os  often  remaining  for  many 
hours  without  any  appreciable  alteration,  its  edges  being  thin  and 
tightly  stretched  over  the  head.  Less  often,  and  this  is  generally 
met  with  in  stout  plethoric  women,  the  edges  of  the  os  are  thick 
and  tough. 


340  LABOR. 

Effects. — The  effects  of  prolongation  of  labor  from  this  cause  will 
vary  much  under  different  circumstances.  If  the  liquor  amnii  be 
prematurely  evacuated,  the  presenting  part  presses  directly  upon  the 
cervix,  and  the  case  is  then  practically  the  same  as  if  the  labor  were 
in  the  second  stage.  Hence  grave  symptoms  may  soon  develop  them- 
selves,, and  early  interference  may  be  imperatively  demanded.  If  the 
membranes  be  unruptured,  delay  will  be  of  comparatively  little 
moment,  and  considerable  time  may  elapse  without  serious  detriment 
to  either  the  mother  or  child. 

Treatment. — The  treatment  will  naturally  vary  much  with  the 
cause,  and  the  state  of  the  patient.  In  the  majority  of  cases,  especi- 
ally if  the  membranes  be  still  intact,  patience  and  time  are  sufficient 
to  overcome  the  obstacle ;  but  it  is  often  in  the  power  of  the  ac- 
coucheur materially  to  aid  dilatation  by  appropriate  management. 
Sometimes  nature  overcomes  the  obstruction  by  lacerating  the  oppos- 
ing structures,  and  cases  are  on  record  in  which  even  a  complete 
ring  of  the  cervix  has  been  torn  off',  and  come  away  before  the  head. 

Many  remedies  have  been  recommended  for  facilitating  dilatation, 
some  of  which  no  doubt  act  beneficially.  Amongst  those  most 
frequently  resorted  to  was  venesection,  and  with  it  was  generally 
associated  the  administration  of  nauseating  doses  of  tartar  emetic. 
Both  these  acted  by  producing  temporary  depression,  under  which 
the  resistance  of  the  soft  parts  was  lessened.  They  probably  answered 
best  in  cases  in  which  there  was  a  rigid  and  tough  cervix ;  and  they 
might  prove  serviceable,  even  yet,  in  stout  plethoric  women  of  robust 
frame.  Practically  they  are  now  seldom,  if  ever,  employed,  and 
other  and  less  debilitating  remedies  are  preferred.  The  agent,  par 
excellence,  which  is  most  serviceable  is  chloral,  which  is  of  special 
value  in  the  more  common  cases  in  which  rigidity  is  associated  with 
spasmodic  contraction  of  the  muscular  fibres  of  the  cervix.  Two  to 
three  doses  of  15  grains,  repeated  at  intervals  of  twenty  minutes,  are 
often  of  almost  magical  efficacy,  the  pains  becoming  steady  and 
regular,  and  the  os  gradually  relaxing  sufficiently  to  allow  the  passage 
of  the  head.  Chloroform  acts  much  in  the  same  way,  but  on  the 
whole  less  satisfactorily,  its  effects  being  often  too  great ;  while  the 
peculiar  value  of  chloral  is  its  influence  in  promoting  relaxation  of 
the  tissues,  without  interfering  with  the  strength  of  the  pains. 

Local  Means  of  Treatment. — Various  local  means  of  treatment  may 
be  also  advantageously  used.  One  is  the  warm  bath,  wrhich  is  much 
used  in  France.  It  is  of  unquestionable  value  where  there  is  much 
rigidity,  and  may  be  used  either  as  an  entire  bath,  or  as  a  hip  bath,  in 
which  the  patient  sits  from  twenty  minutes  to  half  an  hour.  The  objec- 
tion is  the  fuss  and  excitement  it  causes,  and,  for  this  reason,  it  is  an 
expedient  seldom  resorted  to  in  this  country.  A  similar  effect  is  pro- 
duced, and  much  more  easily,  by  a  douche  of  tepid  water  upon  the 
cervix.  This  can  be  very  easily  administered,  the  pipe  of  a  Higgin- 
son's  syringe  being  guided  up  to  the  cervix  by  the  index  finger  of 
the  right  hand,  and  a  stream  of  water  projected  against  it  for  five 
or  ten  minutes.  Smearing:  the  os  with  extract  of  belladonna  is 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  341 

advised  by  Continental  authorities,  but  its  effects  are  more  than 
doubtful. 

Artificial  dilatation  of  the  cervix  by  the  finger  has  often  been  re- 
commended, and  has  been  the  subject  of  much  discussion,  especially 
in  the  Edinburgh  school,  where  it  was  formerly  commonly  employed. 
It  is  capable  of  being  very  useful,  but  it  rnav  also  do  much  injury 
when  roughly  and  injudiciously  used.  The  class  of  cases  in  which 
it  is  most  serviceable  are  those  in  which  the  liquor  arnnii  has  been 
long  evacuated,  and  in  which  the  head,  covered  by  the  tightly 
stretched  cervix,  has  descended  low  into  the  pelvic  cavity.  Under 
these  circumstances,  if  the  finger  be  passed  gently  within  the  os 
during  a  pain,  and  its  margin  pressed  upwards  and  over  the  head, 
as  it  were,  while  the  contraction  lasts,  the  progress  of  the  case  may  be 
materially  facilitated.  This  manoeuvre  is  somewhat  similar  to  that 
which  has  been  already  spoken  of,  when  the  anterior  lip  of  the  cervix 
is  caught  between  the  head  and  the  pubic  bone,  and,  if  properly  per- 
formed, I  believe  it  to  be  quite  safe,  and  often  of  great  value.  It  is 
not,  however,  well  adapted  for  those  cases  in  which  the  membranes  are 
still  intact,  or  in  which  the  os  remains  undilated  when  the  head  is 
still  high  in  the  pelvis.  When  there  is  much  delay  under  these  condi- 
tions, and  interference  of  some  kind  seems  called  for,  the  dilatation 
may  be  much  assisted  by  the  use  of  caoutchouc  dilators,  described 
in  the  chapter  on  the  induction  of  premature  labor,  which  imitate 
nature's  method  of  opening  up  the  os,  and  also  act  as  a  direct  stimu- 
lant to  uterine  contraction.  But  it  should  be  remembered,  that  it  is 
precisely  in  such  cases  that  delay  is  least  prejudicial.  If,  however, 
the  os  be  excessively  long  in  opening,  its  dilatation  may  be  safely 
and  efficiently  promoted  by  passing  within  it,  and  distending  with 
water,  one  of  the  smallest  sized  bags ;  and,  after  this  has  been  in 
position  from  ten  to  twenty  minutes,  it  may  be  removed,  and  a  larger 
one  substituted. 

Rigidity  depending  upon  Organic  Caiises. — Every  now  and  again 
we  meet  with  cases  in  which  the  obstacle  depends  upon  organic 
changes  in  the  cervix,  the  most  common  of  which  are  cicatricial 
hardening  from  former  lacerations ;  hypertrophic  elongation  of  the 
cervix  from  disease  antecedent  to  pregnancy ;  or  even  agglutination 
and  closure  of  the  os  uteri.  Cicatrices  are  generally  the  result  of 
lacerations  during  former  labors.  They  implicate  a  portion  only  of 
the  cervix,  which  they  render  hard,  rigid,  and  undilatable,  while  the 
remainder  has  its  natural  softness.  They  can  readily  be  made  out 
by  the  examining  finger.  A  somewhat  similar,  but  much  more  for- 
midable, obstruction  is  occasionally  met  with  in  cases  of  old  standing 
hypertrophic  elongation  of  the  cervix,  which  is  generally  associated 
with  prolapse.  In  most  cases  of  this  kind  the  cervix  becomes  soft- 
ened during  pregnancy,  so  that  dilatation  occurs  without  any  un- 
usual difficulty.  But  this  does  not  always  happen.  A  good  ex- 
ample is  related  by  Mr.  Roper,  in  the  seventh  volume  of  the  "  Ob- 
stetrical Transactions,"  in  which  such  a  cervix  formed  an  almost 
insuperable  obstacle  to  the  passage  of  the  child. 

Carcinoma  of  the  cervix  uteri,  which  produces  extensive  thicken- 


342  LABOR. 

ing  and  induration  of  its  tissues,  and  even  advanced  malignant  dis- 
ease of  the  uterus,  is  no  bar  to  conception. 

Occlusion  of  the  Os. — Agglutination  of  the  margins  of  the  os  uteri 
is  occasionally  met  with,  and  must,  of  course,  have  occurred  after 
conception.  It  is  generally  the  result  of  some  inflammatory  affec- 
tion of  the  cervix  during  the  early  months  of  gestation,  and  I  have 
known  it  recur  in  the  same  woman  in  two  successive  pregnancies. 
Usually  it  -is  not  associated  with  any  hardness  or  rigidity,  but  the 
entire  cervix  is  stretched  over  the  presenting  part,  and  forms  a 
smooth  covering,  in  which  the  os  may  only  exist  as  a  small  dimple, 
and  may  be  very  difficult  to  detect  at  all.  [Occlusion  of  the  os  uteri 
from  inflammatory  change,  sometimes  so  alters  the  cervix,  that  no 
sign  of  the  original  opening  can  be  discovered ;  and  in  two  such  in- 
stances, the  Csesarean  operation  has  been  performed  in  the  United 
States,  by  which  the  women  were  saved. — ED]. 

Their  Treatment. — Any  of  these  mechanical  causes  of  rigidity  may 
at  first  be  treated  in  the  same  way  as  the  more  simple  cases;  au'd 
with  patience,  the  use  of  chloral  and  chloroform,  and  of  the  fluid 
dilators,  sufficient  expansion  to  permit  the  passage  of  the  head  will 
often  take  place.  But  if  these  methods  produce  no  effect,  and  symp- 
toms of  constitutional  irritation  are  beginning  to  develop  themselves, 
other,  and  more  radical,  means  of  overcoming  the  obstruction  may 
be  required. 

Incision  of  the  Cervix. — Under  such  circumstances  incision  of  the 
cervix  maybe  not  only  justifiable  but  essential,  and  it  frequently 
answers  extremely  well.  On  the  Continent  it  is  resorted  to  much 
more  frequently  and  earlier  than  in  this  country,  and  with  the  most 
beneficial  results.  The  operation  offers  no  difficulties.  The  simplest 
way  of  performing  it  is  to  guard  the  greater  portion  of  the  blade  of 
a  straight  blunt-pointed  bistoury  by  wrapping  lint  or  adhesive  plas- 
ter round  it,  leaving  about  half  an  inch  cutting  edge  towards  its 
point.  This  is  guided  to  the  cervix,  on  the  under  surface  of  the 
index  finger,  and  three  or  four  notches  are  cut  in  the  circumference 
of  the  os  to  about  the  depth  of  a  quarter  of  an  inch.  Very  gener- 
ally, especially  when  the  obstruction  is  only  due  to  old  cicatrices,  the 
pains  will  now  speedily  effect  complete  expansion,  which  may 
be  very  advantageously  aided  by  applying  the  hydrostatic  dilators. 
When  the  obstruction  is  due  to  carcinomatous  infiltration  or  inflam- 
matory thickening,  the  case  is  much  more  complicated,  and  will 
painfully  tax  the  resources  of  the  accoucheur.  Still  there  can  be  no 
question  that  incisions  should  form  a  preliminary  to  any  subsequent 
proceedings  that  may  be  necessary,  as  they  are,  at  the  worst,  not 
likely  to  increase  in  the  least  the  risks  the  patient  has  to  run,  and 
they  may  possibly  avert  more  serious  operations.  In  the  case  of 
malignant  disease  the  risk  of  serious  hemorrhage,  from  the  great 
vascularity  of  the  tissues,  must  not  be  forgotten,  and,  if  necessary, 
means  must  be  taken  to  check  this  by  local  styptics,  such  as  per- 
chloride  of  iron.  If  incision  fail,  and  the  state  of  the  patient  de- 
mands speedy  delivery,  it  may  be  necessary  to  reduce  the  bulk  of 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS. 

the  child  by  perforation,  or,  iu  the  worst  case  of  malignant  infiltra- 
tion, even  to  resort  to  the  Caesarean  section. 

Application  of  the  Forceps  icitltin  the  Cervix. — Before  performing 
craniotomy,  when  the  os  is  sufficiently  open,  a  cautious  application 
of  the  forceps  is  quite  justifiable.  Steady  and  careful  downward 
traction,  combined  with  digital  expansion,  has  often  enabled  a  head 
to  pass  with  safety  through  an  os  that  has  resisted  all  other  means 
of  dilatation,  and  the  destruction  of  the  child  has  thus  been  avoided. 
If,  indeed,  the  os  appear  to  be  dilatable,  this  procedure  may  advan- 
tageously be  adopted  before  incision,,  and,  as  a  matter  of  tact,  it  is 
commonly  practised  in  the  Rotunda  Hospital.  An  operation  involv- 
ing, beyond  doubt,  of  itself  some  risk,  and  requiring  considerable 
operative  dexterity,  would  naturally  not  be  lightly  and  inconsider- 
ately undertaken.  But  when  it  is  remembered  that  the  alternative 
is  the  destruction  of  the  child,  the  risk  of  exhaustion,  and  at  least 
as  great  mechanical  injury  to  the  mother,  its  difficulty  need  not  stand 
in  the  way  of  its  adoption. 

Treatment  when  Occlusion  of  the  Os  Exists. — When  the  os  is  appa- 
rently obliterated,  incision  is  the  only  resource.  Before  resorting  to 
it  the  patient  should  be  placed  under  chloroform,  and  the  entire  lower 
segment  of  the  uterus  carefully  explored.  Possibly  the  aperture 
may  be  found  high  up,  and  out  of  reach  of  an  ordinary  examination, 
or  we  may  detect  a  depression  corresponding  to  its  site.  A  small 
crucial  incision  may  then  be  made  at  the  site  of  the  os,  if  this  can 
be  ascertained ;  if  not,  at  the  most  prominent  portion  of  the  cervix. 
Very  generally  the  pains  will  then  suffice  to  complete  expansion, 
which  may  be  further  aided  by  the  fluid  dilators. 

Bands  and  Cicatrices  in  the  Vagina. — Extreme  rigidity  of  the 
vagina,  or  bands  and  cicatrices  in  or  across  its  walls,  the  result  of 
congenital  malformation,  of  injuries  in  former  labors,  or  of  antece- 
dent disease,  occasionally  obstruct  the  second  stage.  There  is  seldom 
any  really  formidable  difficulty  from  this  cause,  since  the  obstruction 
almost  always  yields  to  the  pressure  of  the  presenting  part.  If  there 
be  any  considerable  extent  of  cicatrices  in  the  vagina,  artificial  assist- 
ance may  be  required.  If  we  should  be  aware,  of  their  existence 
during  pregnancy,  and  find  them  to  be  sufficiently  dense  and  ex- 
tensive to  be  likely  to  interfere  with  delivery,  an  endeavor  may  be 
made  to  dilate  them  gradually  by  hydrostatic  bags  or  bougies.  If 
they  be  not  detected  until  labor  is  in  progress,  we  must  be  guided  in 
our  procedures  by  the  pressure  to  which  they  are  subjected.  It  may 
then  be  necessary  to  divide  them  with  a  knife,  and  to  hasten  the 
passage  of  the  head  by  the  forceps,  so  as  to  prevent  contusion  as 
much  as  possible.  It  is  obviously  impossible  to  lay  down  any  posi- 
tive rules  for  such  rare  contingencies,  the  treatment  suitable  for  which 
must  necessarily  vary  much  with  the  individual  peculiarities  of  the 
case. 

Extreme  rigidity  of  the  perineum  is  often  dependent  upon  cicatricial 
hardening  from  injury  in  previous  labors.  This  may  greatly  inter- 
fere with  its  dilatation ;  and  if  laceration  seem  inevitable,  we  'may  be 
quite  justified  in  attempting  to  avert  it  by  incision  of  the  margins  of 


3-U  LABOR. 

the  perineum,  on  the  principle  of  a  clean  cut  being  always  preferable 
to  a  jagged  tear. 

Labor  Complicated  ivith  Tumor. — Occasionally  we  meet  with  very 
formidable  obstacles  from  tumors  connected  with  the  maternal  struc- 
tures. These  are  most  commonly  either  fibroid  or  ovarian,  although 
others  may  be  met  with,  such  as  malignant  growths  from  the  pelvic 
bones,  exostoses,  etc. 

Fibroid  Tumors  of  the  Uterus. — Considering  the  frequency  with 
which  women  suffer  from  fibroid  tumors  of  the  uterus,  it  is  perhaps 
somewhat  remarkable  that  they  do  not  more  often  complicate  de- 
livery. Probably  women  so  affected  are  not  apt  to  conceive.  Occa- 
sionally, however,  cases  of  this  kind  cause  much  anxiety.  Of  course, 
the  cases  are  most  grave  in  which  the  tumors  are  so  situated  as  to 
encroach  upon  the  cavity  of  the  pelvis,  and  mechanically  obstruct 
the  passage  of  the  child.  Even  those  in  which  this  does  not  occur 
are  by  no  means  free  from  danger,  for  interstitial  and  sub-peritoneal 
fibroids,  situated  in  the  upper  parts  of  the  uterus,  and  leaving  the 
pelvic  cavity  quite  unimplicated,  may  interfere  with  the  action  of 
the  uterine  fibres,  prevent  subsequent  contraction,  cause  profuse  post- 
partum  hemorrhage,  or  even  predispose  to  rupture  of  the  uterine 
tissue.  Hence,  every  case  in  which  the  existence  of  uterine  fibroids 
has  been  ascertained  must  be  anxiously  watched.  The  risk  of  hemor- 
rhage is  perhaps  the  greatest ;  for,  if  the  tumors  be  at  all  large,  effi- 
cient contraction  of  the  uterus  after  the  birth  of  the  child  must  be 
more  or  less  interfered  with.  Fortunately  it  is  not  so  common  as 
might  almost  be  expected.  Out  of  5  cases  recorded  in  the  "  Obstet- 
rical Transactions,"  2  of  which  were  in  my  own  practice,  no  hemor- 
rhage occurred ;  nor  does  it  seem  to  have  happened  in  any  of  the  26 
cases  collected  by  Magdelaine  in  his  thesis  on  the  subject.  I  recently 
saw  an  interesting  example  of  this  in  a  patient,  whose  case  was 
looked  forward  to  with  much  anxiety,  in  consequence  of  the  exist- 
ence of  several  enormous  fibroid  masses  projecting  from  the  fundus 
and  anterior  surface  of  the  body  of  the  uterus,  and  whose  labor  was, 
nevertheless,  typically  normal  in  every  way.  Should  hemorrhage 
occur  after  delivery,  the  injection  of  styptic  solutions  would  probably 
be  peculiarly  valuable,  since  the  ordinary  means  of  promoting  con- 
traction are  likely  to  fail. 

It  is  when  the  fibroid  growths  implicate  the  lower  uterine  zone 
and  the  cervical  region,  that  the  greatest  difficulties  are  likely  to  be 
met  with.  The  practice  then  to  be  adopted  must  be  regulated  to  a 
great  extent  by  the  nature  of  each  individual  case.  If  it  be  possible 
to  push  the  tumor  above  the  pelvic  brim,  out  of  the  way  of  the  pre- 
senting part,  that,  no  doubt,  is  the  best  course  to  pursue,  as  not 
only  clearing  the  passage  in  the  most  effectual  way,  but  removing 
the  tumor  from  the  bruising  to  which  it  would  otherwise  be  subjected 
when  pressed  between  the  head  and  the  pelvic  walls,  which  seems  to 
be  one  of  the  greatest  dangers  of  this  complication.  This  manoeuvre 
is  sometimes  possible  in  what  seem  to  be  the  most  unpromising 
circumstances.  An  interesting  example  is  narrated  by  Mr.  Spencer 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS. 


345 


Wells,1  who,  called  to  perform  the  Csesarean  section,  succeeded, 
although  not  without  much  difficulty",  in  pushing  the  obstructing 
mass  above  the  brim,  the  child  subsequently  passing  with  ease.  I 
have  myself  elsewhere  recorded  two  similar  cases2  in  which  I  was 
enabled  to  deliver  the  patient  by  pushing  up  the  obstructing  tumor, 
in  both  of  which  the  Crcsarean  section  would  have  been  inevitable  had 
the  attempt  at  reposition  failed.  Therefore,  before  resorting  to  more 
serious  operative  procedures,  a  determined  effort  at  pushing  the 
tumor  out  of  the  way  should  be  made,  the  patient  being  deeply 
chloroformed,  and,  if  necessary,  upward  pressure  being  made  by  the 
closed  fist  passed  into  the  vagina. 

Enucleation  or  Ablation. — Failing  this,  the  possibility  of  enuclea- 
ting the  tumor,  or,  if  that  be  not  possible,  of  removing  it  piecemeal 
with  the  e*craseur,  should  be  considered.  On  account  of  the  loose 
attachments  of  these  growths,  and  the  facility  with  which  they  can 
be  removed  in  this  way  in  the  non -pregnant  state,  the  expedient  seems 
certainly  well  worthy  of  a  trial,  if  their  site  and  attachments  render 
it  at  all  feasible.  Interesting  examples  of  the  successful  performance 
of  this  operation  are  recorded  by  Danyau  and  Braxton  Hicks. 
Should  it  be  found  impracticable,  the  case  must  be  managed  in  refer- 
ence to  the  amount  of  obstruction ;  and  the  forceps,  craniotomy,  or 
even  the  Caesarean  section,  may  be  necessary.3 

Tumors  of  the  Ovaries. — The  next  most  common  class  of  obstruct- 
ing tumors  are  those  of  the  ovary  (Fig.  120),  and  it  is  apparently 


Labor  Complicated  by  Ovarian  Tumor. 

1  Obst.  Trans.,  vol.  ix.  p.  73.  2  Obst.  Trans.,  vol.  xix.  p.  101. 

[3  The  great  objection  to  the  Caesarean  operation,  lies  in  the  fact,  that  this  class  of 
cases  is  the  most  fatal  of  all  in  which  this  mode  of  delivery  has  been  practised ;  the 
great  danger  arising  from  hemorrhage. — ED.] 
23 


LABOR. 

not  the  largest  of  these  which  are  most  apt  to  descend  into  the  pelvic 
cavity.  When  the  tumor  is  of  any  considerable  size,  its  bulk  is 
such  that  it  cannot  be  contained  in  the  true  pelvis,  and  it  rises  into 
the  abdominal  cavity  with  the  uterus.  Hence,  the  existence  of  the 
tumor  that  offers  the  most  formidable  obstacle  to  delivery  is  rarely 
suspected  before  labor  sets  in. 

In  order  to  estimate  the  results  of  the  various  methods  of  treat- 
ment, I  have  tabulated  57  cases.1  In  13  labor  was  terminated  by 
the  natural  powers  alone  ;  but  of  these  6  mothers,  or  nearly  one-half, 
died.  In  favorable  contrast  with  these  we  have  the  cases  in  which 
the  size  of  the  tumor  was  diminished  by  puncture.  These  are  9  in 
number,  in  all  of  which  the  mothers  recovered;  6  out  of  the  9 
children  being  saved.  The  reason  of  the  great  mortality  in  the 
former  cases  is  apparently  the  bruising  to  which  the  tumor,  even 
when  small  enough  to  allow  the  child  to  be  squeezed  past  it,  is  neces- 
sarily subjected.  This  is  extremely  apt  to  set  up  a  fatal  form  of 
diffuse  inflammation,  the  risk  of  which  was  long  ago  pointed  out  by 
Ashwell,2  who  draws  a  comparison  between  cases  in  which  such 
tumors  have  been  subjected  to  contusion  and  cases  of  strangulated 
hernia ;  and  the  cause  of  death  in  both  is  doubtless  very  similar. 
This  danger  is  avoided  when  the  tumor  is  punctured,  so  as  to  become 
flattened  between  the  head  and  the  pelvic  walls.  On  this  account,  I 
think,  it  should  be  laid  down  as  a  rule  that  puncture  should  be  per- 
formed in  all  cases  of  ovarian  tumor  engaged  in  front  of  the  pre- 
senting part,  even  when  it  is  of  so  small  a  size  as  not  to  preclude  the 
possibility  of  delivery  by  the  natural  powers. 

Treatment  tvhen  Puncture  Fails. — In  5  of  the  57  cases  it  was  found 
possible  to  return  the  tumor  above  the  pelvic  brim,  and  in  these  also 
the  termination  was  very  favorable,  all  the  mothers  recovering. 
Should  puncture  not  succeed,  and  it  may  fail  on  account  of  the  gelati- 
nous and  semi-solid  nature  of  the  contents  of  the  cyst,  it  may  be 
possible  to  dispose  of  the  tumor  in  this  way,  even  when  it  seems  to 
be  firmly  wedged  down  in  front  of  the  presenting  part,  and  to  be 
hopelessly  fixed  in  its  unfavorable  position. 

Failing  either  of  these  resources,  it  may  be  necessary  to  resort  to 
craniotomy,  provided  the  size  of  the  tumor  precludes  the  possibility 
of  delivery  by  forceps. 

The  question  of  the  effect  on  labor  of  ovarian  tumor  which  does 
not  obstruct  the  pelvic  canal  is  one  of  some  interest,  but  there  are 
not  a  sufficient  number  of  cases  recorded  to  throw  much  light  on  it. 
I  am  disposed  to  think  that  labor  generally  goes  on  favorably.  What 
delay  there  is  depends  on  the  inefficient  action  of  the  accessory  mus- 
cles engaged  in  parturition,  on  account  of  the  extreme  distension  of 
the  abdomen. 

Polypus. — [Polypoid  tumors  sometimes  act  as  serious  obstacles  to 
delivery.  If  long-pedicled  they  may  pass  out  of  the  vagina  in  ad- 
vance of  the  foetus.  If  more  firmly  attached,  they  may  be  pushed 
up  and  secured  by  bringing  down  the  child.  They  are  sometimes 

1  Obst.  Trans.,  vol.  ix.  *  Guy's  Hospital  Reports,  vol.  5i. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  347 

detached  and  expelled  during  the  labor,  by  the  pressure  of  the  head: 
or  are  removed  by  an  ecraseur  if  recognized  early. — ED.] 

There  are  a  few  other  conditions,  connected  with  the  maternal 
structures,  which  may  impede  delivery,  but  which  are  of  compara- 
tively rare  occurrence. 

Vaginal  Cystocele. — Amongst  them  is  vaginal  cystocelc,  consisting 
of  a  prolapse  of  the  distended  bladder  in  front  of  the  presentation, 
where  it  forms  a  tense  fluctuating  pouch,  which  has  been  mistaken 
for  an  hydrocephalic  head,  or  for  the  bag  of  membranes.  This  com- 
plication is  only  likely  to  arise  when  the  bladder  has  been  allowed  to 
become  unduly  distended  from  want  of  attention  to  the  voiding  of 
urine  during  labor.  The  diagnosis  should  not  offer  any  difficulty, 
for  the  finger  will  be  able  to  pass  behind,  but  not  in  front  of,  the 
swelling,  and  reach  the  presenting  part ;  while  the  pain  and  tenesmus 
will  further  put  the  practitioner  on  his  guard.  The  treatment  con- 
sists in  emptying  the  bladder ;  but  there  may  be  some  difficulty  in 
passing  the  catheter  in  consequence  of  the  urethra  being  dragged 
out  of  its  natural  direction.  A  long  elastic  male  catheter  will 
almost  always  pass,  if  used  with  care  and  gentleness.  Should  it  be 
found  impossible  to  draw  off  the  water,  and  this  is  said  to  have  some- 
times happened,  the  tense  pouch  might  be  punctured  without  danger 
by  the  fine  needle  of  an  aspirator  trocar,  and  its  contents  withdrawn. 
When  once  the  viscus  is  emptied,  it  can  easily  be  pushed  above  the 
presenting  part  in  the  intervals  between  the  pains. 

Vesical  Calculus. — In  some  few  cases  difficulties  have  arisen  from 
the  existence  of  a  vesical  calculus.  Should  this  be  pushed  down  in 
front  of  the  head,  it  can  readily  be  understood  that  the  maternal 
structures  would  run  the  risk  of  being  seriously  bruised  and  injured. 
Should  we  make  out  the  existence  of  a  calculus — and,  if  the  presence 
of  one  be  suspected,  the  diagnosis  could  easily  be  made  by  means  of 
a  sound — an  endeavor  should  be  made  to  push  it  above  the  brim  ot 
the  pelvis.  If  that  be  found  to  be  impossible,  no  resource  is  left  but 
its  removal,  either  by  crushing,  or  by  rapid  dilatation  of  the  urethra, 
followed  by  extraction.  Should  we  be  aware  of  the  existence  of  a 
calculus  during  pregnancy,  its  removal  should  certainly  be  under- 
taken before  labor  sets  in. 

Hernial  protrusion  in  Douglas's  space  may  sometimes  give  rise  to 
anxiety  from  the  pressure  and  contusion  to  which  it  is  necessarily 
subjected.  An  endeavor  must  be  made  to  replace  it,  and  to  moderate 
the  straining  efforts  of  the  patient ;  and  it  may  be  even  advisable  to 
apply  the  forceps  so  as  to  relieve  the  mass  from  pressure  as  soon  as 
possible.  It  is,  however,  of  great  rarity.  Fordyce  Barker,  in  an 
interesting  paper  on  the  subject,1  records  several  examples,  and  states 
that  he  has  met  with  no  instance  in  which  it  has  led  to  a  fatal  result 
either  to  mother  or  child,  although  it  cannot  but  be  considered  a 
serious  complication. 

Scybalous  masses  in  the  intestine  may  be  so  hard  and  impacted  as 
to  form  an  obstruction.  The  necessity  of  attending  to  the  state  of 

1  Amer.  Journ.  of  Obstetrics,  vol.  ix. 


348  LABOR. 

the  rectum  has  already  been  pointed  out.  Should  it  be  found  im- 
possible to  empty  the  bowel  by  large  enemata,  the  mass  must  be 
mechanically  broken  down  and  removed  by  the  scoop. 

(Edema  of  the  Vulva. — Excessive  ocdematous  infiltration  of  the 
vulva  may  sometimes  cause  obstruction,  and  require  diminution  in 
size,  which  can  be  easily  effected  by  numerous  small  punctures. 

Haematic  effusions  into  the  cellular  tissue  of  the  vulva  or  vagina 
form  a  grave  complication  of  labor.  Such  blood  swellings  are  most 
usually  met  with  in  one  or  both  labia,  or  under  the  vaginal  wall ;  in 
the  gravest  forms,  the  blood  may  extend  into  the  tissues  for  a  con- 
siderable distance,  as  in  the  case  recorded  by  Cazeaux,  where  it 
reached  upwards  as  far  as  the  umbilicus  in  front,  and  as  far  as  the 
attachment  of  the  diaphragm  behind. 

Conditions  favoring  the  Accident. — The  conditions  associated  with 
pregnancy,  the  distension  and  engorgement  to  which  the  vessels  are 
subjected,  the  interference  with  the  return  of  the  blood  by  the  pres- 
sure of  the  head  during  labor,  and  the  violent  efforts  of  the  patient, 
afforded  a  ready  explanation  of  the  reason  why  a  vessel  may  be 
predisposed  to  rupture  and  admit  of  the  extravasation  of  blood. 

The  accident  is  fortunately  far  from  a  common  one,  although  a 
sufficient  number  of  cases  are  recorded  to  make  us  familiar  with  its 
symptoms  and  risks.  The  dangers  attending  such  effusions  would 
seem  to  be  great,  if  the  statistics  given  by  those  who  have  written 
on  the  subject  are  to  be  trusted.  Thus,  out  of  124  cases  collected 
by  various  French  authors,  44  proved  fatal.  Fordyce  Barker  points 
out  that,  since  the  nature  and  appropriate  treatment  of  the  accident 
have  been  more  thoroughly  understood,  the  mortality  has  been  much 
lessened ;  for  out  of  15  cases  reported  by  Scanzoni  only  1  died,  and 
out  of  22  cases  he  had  himself  seen  2  died,  and  all  these  three  deaths 
were  from  puerperal  fever,  and  not  the  direct  result  of  the  accident.1 

Situation  of  the  Blood  Effusions. — The  blood  may  be  effused  into 
any  part  of  the  pelvic  cellular  tissue,  or  into  the  labia.  The  accident 
most  often  happens  during  labor  when  the  head  is  low  down  in  the 
pelvis,  not  unfrequently  just  as  it  is  about  to  escape  from  the  vulva. 
Hence  the  extravasation  is  more  often  met  with  low  down  in  the 
vagina,  and  more  frequently  in  one  of  the  labia  than  in  any  other 
situation.  I  have  met  with  a  case  in  which  I  had  every  reason  to 
believe  that  an  extravasation  of  blood  had  occurred  within  the 
tissues  immediately  surrounding  the  cervix.  It  is  natural  to  suppose 
that  a  varicose  condition  of  the  veins  about  the  vulva  would  pre- 
dispose to  the  accident,  but  in  most  of  the  recorded  examples  this 
is  not  stated  to  have  been  the  case.  Still,  if  varicose  veins  exist  to 
any  marked  degree,  some  anxiety  on  this  point  cannot  but  be  felt. 

Time  of  Occurrence. — The  thrombus  occasionally,  though  rarely, 
forms  before  delivery.  Most  commonly  it  first  forms  towards  the  end 
of  labor,  or  after  the  birth  of  the  child.  In  the  latter  case,  it  is  pro- 
bable that  the  laceration  in  the  vessels  occurred  before  the  birth  of 

1  The  Puerperal  Diseases,  p.  60. 


OBSTRUCTION    FROM    CONDITION    OF    SOFT    PARTS.  349 

the  child,  and  that  the  pressure  of  the  presenting  part  prevented  the 
escape  of  any  quantity  of  blood  at  the  time  of  laceration. 

Symptoms. — The  symptoms  are  not  by  any  means  characteristic. 
Pain  of  a  tearing  character,  occasionally  very  intense,  and  extending 
to  the  back  and  down  the  thighs,  is  very  generally  associated  with  the 
formation  of  the  thrombus.  If  a  careful  physical  examination  be 
made,  the  nature  of  the  case  can  readily  be  detected.  When  the  blood 
escapes  into  the  labium,  a  firm,  hard  swelling  is  felt,  which  has  even 
been  mistaken  for  the  foetal  head.  If  the  effusion  implicate  the  in- 
ternal parts  only,  the  diagnosis  may  not  at  first  be  so  evident.  But 
even  then  a  little  care  should  prevent  any  mistake,  for  the  swelling  may 
be  felt  in  the  vagina,  and  may  even  form  an  obstacle  to  the  passage 
of  the  child.  Cazeaux  mentions  cases  in  which  it  was  so  extensive 
as  to  compress  the  rectum  and  urethra,  and  even  to  prevent  the  exit 
of  the  lochia.  In  some  cases  the  distension  of  the  tissues  is  so  great 
that  they  lacerate,  and  then  hemorrhage,  sometimes  so  profuse  as 
directly  to  imperil  the  life  of  the  patient,  may  occur.  The  bursting 
of  the  skin  may  take  place  sometime  subsequent  to  the  formation  of 
the  thrombus.  Constitutional  symptoms  will  be  in  proportion  to  the 
amount  of  blood  lost,  either  by  extravasation,  or  externally,  after 
the  rupture  of  the  superficial  tissues.  Occasionally  they  are  con- 
siderable, and  are  the  same  as  those  of  hemorrhage  from  any  cause. 

Termination. — The  terminations  of  thrombus  are  either  spontane- 
ous absorption,  which  may  occur  if  the  amount  of  blood  extrava- 
sated  be  small ;  or  the  tumor '  may  burst,  and  then  there  is  external 
hemorrhage  ;  or  it  may  suppurate,  the  contained  coagula  being  dis- 
charged from  the  cavity  of  the  cyst ;  or  finally,  sloughing  of  the 
superficial  tissues  has  occurred. 

Treatment. — The  treatment  must  naturally  vary  with  the  size  of  the 
thrombus,  and  the  time  at  which  it  forms.  If  it  be  met  with  during 
labor,  unless  it  be  extremely  small,  it  will  be  very  apt  to  form  an  ob- 
struction to  the  passage  of  the  child.  Under  such  circumstances  it  is 
clearly  advisable  to  terminate  the  labor  as  soon  as  possible,  so  as  to 
remove  the  obstacle  to  the  circulation  in  the  vessels.  For  this  purpose 
the  forceps  should  be  applied  as  soon  as  the  head  can  be  easily  reached. 
If  the  tumor  itself  obstruct  the  passage  of  the  head,  or  if  it  be  of 
any  considerable  size,  it  will  be  necessary  to  incise  it  freely  at  its 
most  prominent  point  and  turn  out  the  coagula,  controlling  the 
hemorrhage  at  once  by  filling  the  cavity  with  cotton  wadding  satu- 
rated in  a  solution  of  perchloride  of  iron,  while,  at  the  same  time, 
digital  compression  with  the  tips  of  the  fingers  is  kept  up.  By  this 
means  pressure  is  applied  directly  to  the  bleeding  point,  and  the 
hemorrhage  can  be  controlled  without  difficulty.  This  is  all  the 
more  necessary  if  spontaneous  rupture  have  taken  place,  for  then  the 
loss  of  blood  is  often  profuse,  and  it  is  of  the  utmost  importance  to 
reach  the  site  of  the  hemorrhage  as  nearly  as  possible. 

If  the  thrombus  be  not  so  large  as  to  obstruct  delivery,  or  if  it  be 
not  detected  until  after  the  birth  of  the  child,  the  question  arises 
whether  the  case  should  not  be  left  alone,  in  the  hope  that  absorption 
may  occur,  as  in  most  cases  of  pelvic  hsematocele.  This  expectant 


850  LABOR. 

treatment  is  advised  by  Cazeaux,  and  it  seems  to  be  the  most  ra- 
tional plan  we  can  adopt.  True  it  may  take  a  longer  time  for  the 
patient  to  convalesce  completely  than  if  the  coagula  were  removed 
at  once,  and  the  hemorrhage  restrained  by  pressure  on  the  bleeding 
point ;  but  this  disadvantage  is  more  than  counterbalanced  by  the 
absence  of  risk  from  hemorrhage,  and  of  septicaemia  from  the  sup- 
puration that  must  necessarily  follow.  Softening  and  suppuration 
may,  in  many  cases,  occur  in  a  few  days,  necessitating  operation,  but 
the  vessels  will  then  be  probably  occluded,  and  the  risk  of  hemor- 
rhage much  lessened.  Dr.  Fordyce  Barker,  however,  holds  the 
opposite  opinion  and  thinks  that  the  proper  plan  is  to  open  the 
thrombus  early,  controlling  the  hemorrhage  in  the  manner  already 
indicated,  unless  the  thrombus  is  situated  high  in  the  vaginal  canal. 

Risk  of  Subsequent  Septicsemia. — Whenever  the  cavity  of  a  throm- 
bus has  been  opened,  either  by  incision,  or  by  spontaneous  softening 
at  some  time  subsequent  to  its  formation,  it  must  not  be  forgotten 
that  there  is  considerable  risk  of  septic  absorption.  To  avoid  this, 
care  must  be  taken  to  use  antiseptic  dressings  freely,  such  as  the 
glycerine  of  carbolic  acid  applied  directly  to  the  part,  and  frequent 
vaginal  injections  of  diluted  Condy's  fluid.  Barker  lays  special 
stress  on  the  importance  of  not  removing  prematurely  the  coagula 
formed  by  the  styptic  applications,  for  fear  of  secondary  hemorrhage, 
but  of  allowing  them  to  come  away  spontaneously. 

[Tetanoid  Falciform  Constriction  of  the  Uterus. — Next  to  deformity 
of  the  pelvis,  this  form  of  obstacle  is  perhaps  the  most  serious  to  be 
met  with,  of  all  those  that  interfere  with  the  birth  of  a  normally 
presenting  foetus.  To  Dr.  Alfred  Hosmer,  of  Watertown,  Massachu- 
setts, must  be  awarded  the  credit  of  having  brought  clearly  before 
the  medical  world  this  rare  form  of  dystocia ;  in  an  article  entitled, 
"J.  peculiar  condition  of  the  cervix  uteri,  which  is  found  in  certain  cases 
of  dystocia"  presented  before  the  Obstetrical  Society  of  Boston,  on 
February  9,  1878,  and  which  will  be  found  in  the  Boston  Medical  and 
/Surgical  Journal,  March  21,  1878,  p.  360.  Attention  having  been 
called  by  him,  to  this  serious,  and  sometimes  fatal  condition  in  par- 
turient women,  several  distant  obstetricians  of  the  United  States 
have  recognized  in  some  of  their  former  cases,  the  descriptions  and 
explanations  given,  and  have  added  materially  to  his  statistical  record 
by  sending  records  of  them  to  him. 

As  it  is  often  said,  "there  is  nothing  new  under  the  sun,"  we  were 
led  to  go  back  a  little  in  history,  after  reading  Dr.  Hosmer's  valuable 
papers,  to  see  if  it  was  possible  that  such  a  marked,  although  rare 
condition,  could  have  been  overlooked  until  this  late  date ;  and  in 
BlundelTs  Obstetric  Medicine,  1840,  p.  166,  we  read  the  following: 
"In  these  turning  cases  you  will  sometimes  meet  with  a  third 
obstruction ;  consisting  in  a  circular  contraction  [italics  his]  of  the 
middle  of  the  womb;  dividing  it  as  it  were  into  an  upper  and  inferior 
chamber;  part  of  the  foetus  lying  in  both.  To  judge  from  two  or 
three  cases  of  this  kind  which  have  fallen  under  my  own  notice,  I 
should  say  that  if  you  proceed  with  gentleness,  resolutely,  yet  cau- 
tiously, and  taking  sufficient  time,  you  will  generally  find  that  the 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.     351 

hand  may,  on  the  whole,  be  passed  through  this  sphincter  with 
tolerable  facility  and  safety  ;  but  beware  of  force  !"  In  another 
place  he  speaks  of  the  obstacle  as  "  the  circular  constriction  of  the 
uterus."  But  this  description  fails  to  set  forth  the  condition,  in  the 
very  serious  and  obstinate  character  in  which  it  appears  to  have 
presented  itself  to  Drs.  Hosmer,  E.  R  Stone,  of  Newton,  Mass., 
C.  A.  Thompson,  of  Jefferson  City,  Mo.,  and  others. 

We  will  give  Dr.  Stone's  case,  to  show  how  serious  an  obstacle 
this  uterine  constriction  may  prove  to  be.  ...  Woman,  30,  priini- 
para,  short  and  stout;  taken  in  labor  September  4,  1876;  pelvis 
somewhat  contracted;  in  labor  70  hours,  when  Dr.  Hosmer  was 
called  in  consultation  ;  os  uteri  well  dilated  ;  occiput  of  child  pre- 
senting; labor  had  been  active,  but  no  advance  of  foetus;  forceps 
applied  and  very  strong  traction  used,  but  to  no  purpose;  hand  in- 
troduced for  version  by  the  feet,  and  constriction  found,  midway 
between  os  and  fundus  uteri,  tightly  grasping  the  foetal  pelvis  ;  after 
much  care  and  effort,  one  foot  was  brought  down,  and  secured  with 
a  loop,  but  no  force  short  of  pulling  off  the  extremity  could  'bring 
down  the  breech  ;  head  was  then  opened  and  emptied,  and  forceps 
again  applied,  but  still  no  advance;  version  was  a  second  time  tried, 
and  by  an  unusual  force,  the  other  leg  was  brought  down  and  a  foetus 
of  six  or  seven  pounds  removed.  The  woman  was  completely  ex- 
hausted and  died  in  72  hours. 

In  a  second  woman,  the  constriction  was  in  the  upper  third  in  each 
of  three  labors,  the  band  being  large,  firm,  and  with  a  sharp  edge  ; 
the  first  child  weighed  9J,  and  was  delivered  alive  by  version;  second, 
10|,  also  living,  and  by  version;  third,  weighed  11  pounds;  forceps 
failed;  version  performed,  and  head  delivered  by  forceps;  still-born; 
woman  died  on  fourth  day.  (Cases  of  Dr.  George  J.  Arnold,  of  Box- 
bury,  Mass.,  in  1872,  1874,  and  1876.) 

In  another  case  reported,  the  woman  presented  the  same  peculiarity 
in  two  labors  ;  and  in  the  first,  the  constriction  could  be  distinctly 
recognized  through  the  abdominal  wall,  the  upper  chamber  contain- 
ing the  body  and  lower  extremities,  being  twice  the  size  of  the  lower; 
delivered  by  craniotomy  and  forceps.  The  second  labor  eighteen 
months  later  ended  fatally  ;  the  woman  dying  undelivered.  (Cases 
of  Dr.  C.  A.  Thompson,  of  Missouri.) 

A  seventh  case  also  died  undelivered,  the  uterus  being  ruptured 
in  the  effort  to  turn  and  bring  down  the  feet.  Of  the  seven  instances 
given,  all  were  head  presentations;  four  were  primiparae;  four  died; 
and  all  the  children  were  lost  but  two.  The  band  felt  to  the  hand 
of  the  operator  more  like  a  sharp  metallic  ring,  than  muscular  tissue, 
and  was  not  in  the  least  influenced  by  anesthesia. 

Dr.  Hosmer  believes  that  the  stricture  is  at  the  internal  os  uteri, 
and  that  the  cervix  is  dilated  to  form  the  lower  chamber.  He  quotes 
in  proof,  a  case  of  dilatation  of  the  cervix  examined  by  Ludwig 
Bandl,  of  Vienna,  in  which  the  os  internum  was  as  high  as  the  um- 
bilicus, the  cervix  was  as  thin  as  paper,  and  covered  more  than  half 
the  foetus  ;  the  forceps  failed,  craniotomy  succeeded,  and  a  child  of 


r-u\  sicKs  CN 


852  LABOR. 

more  than  eight  pounds  delivered;  woman  discharged  Avell  in  two 
weeks. 

According  to  the  statements  of  Dr.  Bandl,  we  see  no  similarity 
between  his  cases  and  those  of  Dr.  Hosrner,  except  the  fact  that  there 
was  in  some  a  constriction.  Healthy  primiparte  in  whom  there  are 
no  evidences  of  a  bladder-like  cervix,  are  the  subjects  of  the  one 
condition ;  and  poor,  anaemic,  feeble  multipart,  in  whom  there  has 
been  developed  an  atony  of  the  cervix  by  repeated  pregnancies,  of 
the  other.  The  latter  is  also  associated  with  some  slight  pelvic  de- 
formity, or  a  transverse  position  of  the  foetus,  and  is  liable  to  result 
in  a  rupture  of  the  thinned  cervix. 

Dr.  Bandl  states,  that  in  very  thin  subjects,  the  attenuated  condition 
of  the  cervix  may  be  felt  through  the  abdominal  walls.  When  labor 
has  some  time  existed  in  such  subjects,  a  constriction  can  be  seen 
about  a  hand-breadth  above  the  symphysis  pubis.  Palpation  still 
more  readily  detects  the  constriction  which  marks  the  dividing  line 
between  the  neck  and  body  of  the  uterus.  A  hand  in  the  uterus 
detects  a  constriction  high  up,  even  surrounding  and  grasping  some 
part  of  the  child. 

This  is  certainly  a  different  form  of  constriction  from  that  given 
by  Dr.  Hosmer ;  in  whose  cases  attenuation  of  the  cervix  would  have 
been  a  ready  means  of  recognizing  the  form  of  dystocia,  if  it  had 
existed.  We  do  not  see  how  there  could  be  a  stricture  at  the  internal 
os  uteri,  if  in  the  upper  third  of  the  uterine  sac,  as  in  the  three  labors 
of  Dr.  Arnold's  patient,  without  a  very  marked  attenuation  of  the 
dilated  neck  of  the  womb.  A  few  cases  somewhat  like  those  in  the 
Vienna  Hospital,  have  occurred  in  this  city,  and  such  was  the  dis- 
tinctness with  which  the  foetus  could  be  felt  through  the  abdominal 
wall,  that  abdominal  pregnancy  was  strongly  suspected,  until  a  normal 
labor  revealed  the  presenting  head.  The  wonder  is  that  they  escaped 
rupture. 

In  a  second  paper  by  Dr.  Hosmer,  published  in  the  journal  before 
quoted,  for  May  30,  1878,  p.  683,  he  enters  into  a  long  physiological 
explanation  of  what  he  conceives  to  be  the  cause  and  character  of 
" ante-partum  hour-glass  contraction  of  the  uterus"  and  recommends 
that  the  Caesarean  operation  should  be  resorted  to  as  promising  the 
most  favorably  for  the  mother. 

We  have  introduced  this  form  of  dystocia  under  a  title,  which 
conveys  to  the  mind  of  the  reader  the  peculiar  nature  of  the  obstruc- 
tion without  any  reference  to  its  exact  seat.  Whether  the  constrict- 
ing ring  is  confined  to  the  internal  os,  or  may  form  at  any  point 
between  it  and  the  circular  fibres  of  the  cornua,  we  cannot  answer 
positively  although  inclined  to  believe  the  latter ;  what  concerns  us 
most  is  to  know  that  there  is  such  a  form  of  dystocia;  that  we  are 
liable  to  meet  with  it ;  that  it  is  dangerous  to  both  foetus  and  mother ; 
how  we  are  to  recognize  it;  and  what  is  best  to  be  done.  The  most 
important  step  in  treatment,  is  an  early  discovery  of  the  existence 
of  the  stricture.  Having  the  knowledge  to  make  us  cautious,  we 
are  to  investigate  the  cause  of  delay  by  a  manual  exploration  of  the 
uterus,  which  has  seldom  been  done,  until  very  late  in  the  labor. 


DYSTOCIA    FROM    FCETUS. 


353 


We  are  then  to  turn  the  foetus,  if  not  too  difficult,  by  reason  of  the 
force  required  ;  failing  in  which,  we  may  at  once  resort  to  gastro- 
hysterotomy  if  the  woman  is  still  in  good  condition  of  strength. 
We  see  no  reason  why  the  incision  in  the  uterus  should  not  be  made 
in  the  usual  way,  as  the  general  contraction  of  the  organ  will  prob- 
ably obliterate  the  stricture.  Laparo-elytrotomy  is  evidently  not 
feasible,  as  the  fcetus  cannot  be  drawn  through  the  cervix.  It  is 
possible  that  morphia  given  to  narcotism,  or  chloral  in  full  doses, 
may  cause  the  ring  to  relax;  but  we  should  have  more  hope  in  an 
early  Coesarean  operation,  being  satisfied  that  it  is  a  much  less  danger- 
ous one  in  our  own  country  than  is  generally  believed.- — -ED.] 


CHAPTER  XI. 

DIFFICULT  LABOR   DEPENDING  ON  SOME   UNUSUAL   CONDITION  OF  THE 

FCETUS. 

Plural  Births. —  The  subject  of  multiple  pregnancy  in  general 
having  already  been  fully  considered,  we  have  now  only  to  discuss  its 
practical  bearing  as  regards  labor.  Fortunately  the  existence  of 
twins  rarely  gives  rise  to  any  serious 
difficulty.  In  the  large  proportion  of 
cases  the  presence  of  a  second  foetus 
is  not  suspected  until  the  birth  of 
the  first,  when  the  nature  of  the  case 
is  at  once  apparent  from  the  fact  of 
the  uterus  remaining  as  large,  or  nearly 
as  large  as  it  was  before. 

There  may  possibly  be  some  delay 
in  the  birth  of  the  first  child,  inasmuch 
as  the  extreme  distension  of  the  uterus 
may  interfere  with  its  thoroughly  effi- 
cient action ;  while,  in  addition,  the 
uterine  pressure  is  not  directly  con- 
veyed to  the  ovum  as  in  single  births, 
but  indirectly  through  the  amniotic  sac 
of  the  second  child  (Fig.  121).  Such 
delay  is  especially  apt  to  arise  when 
the  first  child  presents  by  the  breech, 
for,  even  if  the  body  be  expelled  spon- 
taneously, difficulty  is  likely  to  occur 
with  the  head,  since  the  uterus  does 
not  contract  upon  it  as  is  ordinarily  the 

case.  Hence  the  intervention  of  the  accoucheur  to  save  the  life  of 
the  child,  by  the  extraction  of  the  head,  will  be  almost  a  matter  of 
necessity. 


Twin  Pregnancy,  Breech  and  Head 
presenting. 


354  LABOR. 

Iii  the  majority  of  cases,  after  the  birth  of  the  first  child,  there  is  a 
temporary  lull  in  the  pains,  which  soon  recommence,  generally  in 
from  ten  to  twenty  minutes,  and  the  second  child  is  rapidly  expelled; 
for  on  account  of  the  full  dilatation  of  the  soft  parts,  there  is  no  ob- 
stacle to  its  delivery.  Sometimes  there  is  a  considerable  interval 
before  the  pains  recur,  and  instances  are  recorded  in  which  even 
several  days  have  elapsed  between  the  births  of  the  two  children. 

Treatment. — In  most  cases  the  management  of  twins  does  not  differ 
from  that  of  ordinary  labor.  As  soon  as  we  are  certain  of  the  ex- 
istence of  a  second  foetus,  we  should  inform  the  bystanders,  but  not 
necessarily  the  mother,  to  whom  the  news  might  prove  an  unpleasant 
and  even  dangerous  shock.  Then  having  taken  care  to  tie  the  cord 
of  the  first  child  for  fear  of  vascular  communication  between  the 
placentas,  our  duty  is  to  wait  for  a  recurrence  of  the  pains.  If  these 
come  on  rapidly,  and  the  presentation  of  the  second  foetus  be  normal, 
its  birth  is  managed  in  the  usual  way. 

Management  ivhen  there  is  Delay  after  the  Birth  of  the  First  Child. — 
If  there  be  any  unusual  delay,  we  have  to  consider  the  proper  course 
to  pursue,  and  on  this  the  opinions  of  authorities  differ  greatly. 
Some  advise  a  delay  of  several  hours,  and  even  more,  if  pains  do  not 
recur  spontaneously ;  while  others,  Murphy  for  example,  recommend 
that  the  second  child  should  be  delivered  at  once.  Either  extreme 
of  practice  is  probably  wrong,  and  the  safest  and  best  course  is, 
doubtless,  the  medium  one.  The  second  point  to  bear  in  mind  is, 
that,  in  multiple  pregnancy,  on  account  of  the  extreme  distension  of 
the  uterus,  there  is  a  tendency  to  inertia,  and  consequently  to  post- 
partum  hemorrhage ;  and  that,  therefore,  it  is  better  that  the  birth 
of  the  second  child  should  be  delayed,  even  for  a  considerable  time, 
rather  than  that  the  patient  should  run  the  risk  attending  an  empty 
and  uncontracted  uterus.  If,  however,  uterine  action  be  present, 
there  is  an  obvious  advantage  in  the  delivery  of  the  second  child 
before  the  dilatation  of  the  passages  passes  off. 

Endeavors  should  be  made  to  Excite  Uterine  Action. — The  best  plan 
would  seem  to  be,  if,  after  waiting  a  quarter  of  an  hour,  labor  pains 
do  not  recur,  to  try  and  induce  them  by  uterine  friction  and  pressure, 
and  by  the  administration  of  a  dose  of  ergot,  to  which,  as  there  can 
be  no  obstacle  to  the  rapid  birth  of  the  second  child,  there  can  be 
now  no  objection.  The  membranes  of  the  second  child  should  always 
be  ruptured  at  once,  if  easily  within  reach,  as  one  of  the  speediest 
means  of  inducing- contraction.  If  no  progress  be  made,  and  speedy 
delivery  be  indicated — a  necessity  which  may  arise  either  from  the 
exhausted  state  of  the  patient,  the  presence  of  hemorrhage,  extremely 
feeble  pulsations  of  the  fcetal  heart  (showing  that  the  life  of  the 
second  child  is  endangered),  or  malpresentation  of  the  second  foetus — 
turning  is  probably  the  readiest  and  safest  expedient.  Under  such 
circumstances  the  operation  is  performed  with  great  ease,  since  the 
passages  are  amply  dilated.  After  bringing  down  the  feet,  the  birth 
of  the  body  should  be  slowly  effected,  with  the  view  of  insuring  as 
complete  subsequent  contraction  as  possible.  If  the  head  has  de- 


DYSTOCIA    FROM    FCETUS.  355 

scendcd  into  the  pelvis,  of  course  turning  is  impossible,  and  the  for- 
ceps must  be  applied. 

Difficulties  arising  from  Locked  Twins. — Occasionally  very  serious 
difficulties  arise  from  parts  of  both  foetuses  presenting  simultane- 
ously, and,  either  thus  impeding  the  entrance  of  either  child  into  the 
pelvis,  or  getting  locked  together,  so  as  to  render  delivery  impossible 
without  artificial  aid.  Such  difficulties  are  not  apt  to  arise  in  the 
more  ordinary  cases,  in  which  each  child  has  its  own  bag  of  mem- 
branes, since  then  the  foetuses  are  kept  entirely  separate  ;  but  in  those 
in  which  the  twins  are  contained  in  a  common  amniotic  cavity,  or  in 
which  both  sacs  have  burst  simultaneously.  They  are  very  puzzling 
to  the  obstetrician,  and  it  may  be  far  from  easy  to  discover  the  cause 
of  the  obstruction.  Nor  is  it  possible  to  lay  down  any  positive  rules 
for  their  management,  which  must  be  governed,  to  a  considerable 
extent,  by  the  circumstances  of  each  individual  case. 

Nature  of  these  Cases. — Sometimes  both  heads  present  simultane- 
ously at  the  brim,  and  then  neither  can  enter  unless  they  be  unusu- 
ally small  or  the  pelvis  very  capacious,  when  both  may  descend  ; 
or  rather  the  first  head  may  descend  low  into  the  pelvic  cavity,  and 
then  the  second  head  enters  the  brim,  and  gets  jammed  against  the 

FIG.  122. 


B 


Shows  Head-locking,  both  Children  presenting  Head  first.     (After  Barnes.) 

thorax  of  the  first  child  (Fig.  122).  Eeimann1  relates  a  curious  ex- 
ample of  this,  in  which  he  delivered  the  first  head  with  the  forceps, 
but  found  the  body  would  not  follow,  and,  on  examination,  a  second 
head  was  found  in  the  pelvis.  He  then  applied  the  forceps  to  the 

Arch.  f.  Gynak.  1871. 


356  LABOR. 

second  head ;  the  body  of  the  first  child  was  then  born,  and  after- 
wards that  of  the  second.  Such  a  mechanism  must  clearly  have 
been  impossible  unless  the  pelvis  had  been  extremely  large. 

Both  Heads  Presenting  Simultaneously. — Whenever  both  heads  are 
felt  at  the  brim,  it  will  generally  be  found  possible  to  get  one  out  of 
the  way  by  appropriate  manipulation,  one  hand  being  passed  into 
the  vagina,  the  other  aiding  its  action  from  without.  Then  the  for- 
ceps may  be  applied  to  the  other  head,  so  as  to  engage  it  at  once  in 
the  pelvic  cavity.  If  both  have  actually  passed  int.o  the  pelvis,  as  in 
the  case  just  alluded  to.  the  difficulty  will  be  much  greater.  It  will 
generally  be  easier  to  push  up  the  second  head,  while  the  lower  is 
drawn  out  by  the  forceps,  than  to  deliver  the  second,  leaving  the 
first  in  situ. 

Foot  or  Hand  with  Head. — In  other  cases  a  foot  or  a  hand  may  de- 
scend along  with  the  head,  and  even  the  four  feet  may  present 
simultaneously.  The  rule  in  the  former  case,  is  to  push  the  part 
descending  with  the  head  out  of  the  way,  and,  in  the  latter,  to  dis- 
engage one  child  as  soon  as  possible.  Great  care  is  necessary,  or  we 
might  possibly  bring  down  the  limbs  of  separate  children. 

Two  Heads  Interlocking. — The  most  common  kind  of  difficulty  is 
when  the  first  child  presents  by  the  breech,  and  is  delivered  as  far  as 
the  head,  which  is  then  found  to  be  locked  with  the  head  of  the 
second  child,  which  has  descended  into  the  pelvic  cavity  (Fig.  123). 

Here  it  is  clear  that  the  obstruction  must  be  very  great,  and,  unless 
the  children  are  extremely  small,  insuperable.  The  first  endeavor 
should  be  to  disentangle  the  heads ;  this  is  sometimes  feasible  if  the 
second  be  not  deeply  engaged  in  the  pelvis,  and  the  hand  be  passed 
up  so  as  to  push  it  out  of  the  way.  This  will  but  rarely  succeed  ; 
then  it  may  be  possible  to  apply  the  forceps  to  the  second  head  and 
drag  it  past  the  body  of  the  first  child,  and  this  is  the  method  re- 
commended by  Iteimann,  who  has  written  an  excellent  paper  on  the 
subject.1  Generally  the  sacrifice  of  one  of  the  children  is  essential, 
and  as  the  body  of  the  first  child  must  have  been  born  for  some  time, 
it  is  probable  that  the  pressure  to  which  it  has  been  subjected  will 
have  already  imperilled,  if  it  have  not  destroyed,  its  life,  and  there- 
fore the  plan  usually  recommended  is  to  decapitate.  This  can  easily 
be  done  with  scissors  or  a  wire  ecraseur,  after  which  the  second  child 
is  expelled  without  difficulty,  leaving  the  head  of  the  first  in  utero  to 
be  subsequently  dealt  with. 

Another  mode  of  managing  these  cases  is,  to  perforate  the  upper 
head,  and  draw  it  past  the  lower  with  the  cephalotribe  or  craniotomy 
forceps.  This  plan  has  the  disadvantage  of  probably  sacrificing  both 
children,  since  the  other  child  can  hardly  survive  the  pressure  and 
delay,  whereas  the  former  plan  gives  the  second  child  a  fair  chance  of 
being  born  alive. 

Double  Monsters. — In  connection  with  the  subject  of  twin  labor  we 
may  consider  those  rare  cases  in  which  the  bodies  of  the  foetuses  are 
partially  fused  together.  The  mechanism  and  management  of  de- 

1  American  Journal  of  Obstetrics,  January,  1877. 


DYSTOCIA    FROM    F(ETUS. 


357 


livery  in  cases  of  double  monstrosity  have  attracted  comparatively 
little  attention,  no  doubt  because  authors  have  considered  them 
matters  of  curiosity  merely,  rather  than  of  practical  importance. 


FIG.  123. 


Shows  Head-locking,  first  Child    coming  feet   first ;   Impaction  of  Heads  from  Wedging  in  Brim. 

(After  Barnes.) 

D.  Apex  of   wedge.     E,  C.  Base  of  wedge  which  cannot  enter  brim.      A,  B.  Line  of  decapi- 
tation to  decompose  wedge,  and  enable  head  of  second  child  to  pass. 

The  frequent  occurrence  of  such  monstrosities  in  our  museums, 
and  the  numerous  cases  scattered  through  our  periodical  literature, 
are  sufficient  to  show  that  they  are  not  so  very  rare  as  we  might  be 
inclined  to  imagine ;  and,  as  they  are  likely  to  give  rise  to  formidable 
difficulties  in  delivery,  it  cannot  be  unimportant  to  have  a  clear  idea 
of  the  usual  course  taken  by  nature  in  effecting  such  births,  with 
a  view  of  enabling  us  to  assist  in  the  most  satisfactory  manner  should 
a  similar  case  come  under  our  observation. 

Unfortunately  the  authors,  who  have  placed  on  record  the  birth  of 


358  LABOR. 

double  monsters,  have  generally  occupied  themselves  more  with  a 
description  of  the  structural  peculiarities  of  the  foetuses,  than  with 
the  mechanism  of  their  delivery ;  so  that,  although  the  cases  to  be 
met  with  in  medical  literature  are  very  numerous,  comparatively  few 
of  them  are  of  real  value  from  an  obstetric  point  of  view.  Still,  I 
have  been  able  to  collect  the  details  of  a  considerable  number1  in 
which  the  history  of  the  labor  is  more  or  less  accurately  described ; 
and  doubtless  a  more  extensive  research  would  increase  the  list. 

For  obstetric  purposes  we  may  confine  our  attention  to  four  prin- 
cipal varieties  of  double  monstrosity,  which  are  met  with  far  more 
frequently  than  any  others.  These  are  :— 

A.  Two  nearly  separate  bodies  united  in  front,  to  a  varying  ex- 
tent, by  the  thorax  or  abdomen. 

B.  Two  nearly  separate  bodies  united  back  to  back  by  the  sacrum 
and  lower  part  of  the  spinal  column. 

C.  Dicephalous  monsters,  the  bodies  being  single  below,  but  the 
heads  separate. 

D.  The  bodies  separate  below,  but  the  heads  fixed  are  partially 
united. 

This  classification  by  no  means  includes  all  the  varieties  of  mon- 
sters that  we  may  meet  with.  It  does,  however,  include  all  that  are 
likely  to  give  rise  to  much  difficulty  in  delivery ;  and  all  the  cases  I 
have  collected  may  be  placed  under  one  of  these  divisions. 

The  first  point  that  strikes  us  in  looking  over  the  history  of  these 
deliveries  is  the  frequency  with  which  they  have  been  terminated 
by  the  natural  powers  alone,  without  any  assistance  on  the  part  of 
the  accoucheur.  Thus,  out  of  the  31  cases  no  less  than  20  were  de- 
livered naturally,  and  apparently  without  much  trouble.  Nothing 
can  better  show  the  wonderful  resources  of  nature  in  overcoming 
difficulties  of  a  very  formidable  kind. 

It  is  pretty  generally  assumed  by  authors  that  the  children  are 
necessarily  premature,  and,  therefore  of  small  size,  and  that  delivery 
before  the  full  term  is  rather  the  rule  than  the  exception.  Dugds 
states  that  the  children  are  often  dead,  and  that  putrefaction  has 
taken  place,  which  facilitates  their  expulsion.  Both  these  assump- 
tions seems  to  me  to  have  been  made  without  sufficient  authority,  and 
not  to  be  borne  out  by  the  recorded  facts.  In  only  1  of  the  31  cases 
is  it  mentioned  that  the  children  were  premature ;  nor  is  there  any 
insufficient  reason  that  I  can  see  why  labor  should  commence  before 
the  full  term  of  gestation. 

Class  A. — By  far  the  greatest  number  are  included  in  the  first 
class — that  in  which  the  bodies  are  nearly  separate,  but  united  by  some 
part  of  the  thorax  or  abdomen.  This  is  the  division  which  includes 
the  celebrated  Siamese  Twins,  an  account  of  whose  birth,  I  may  ob- 
serve, I  have  not  been  able  to  discover.  [The  mother  of  these  twins 
was  a  Chinese  half-breed,  short,  and  with  a  broad  pelvis,  and  had 
borne  several  children  previously.  She  stated  on  several  occasions 
in  conversation  with  parties  in  Siam,  that  the  twins  were  born  re- 

1  Obstet.  Trans,  vol.  viii. 


DYSTOCIA    FROM    FCETUS.  359 

versed,  the  feet  of  one  being  followed  by  the  head  of  the  other,  and 
that  they  were  very  small  and  feeble  at  birth  and  for  several  months 
afterwards.  The  twins  confirmed  this  statement  by  affirming  that 
they  could  when  little  boys  at  play  on  the  ground,  turn  themselves 
end  for  end  upon  the  ensiform  attachment,  up  to  the  age  of  ten  or 
twelve,  the  attachment  being  then  soft  and  pliable. — -ED.]  Out  of  the 
31  cases,  19  come  under  this  heading.  The  details  of  the  labor  are 
briefly  as  follows : — 1  died  undelivered  ;  8  were  terminated  by  the 
natural  powers,  in  3  of  which  the  feet,  and  in  3  the  head  presented ; 
in  2  the  presentation  is  doubtful ;  6  were  delivered  by  turning,  or  by 
traction  on  the  lower  extremities ;  4  were  delivered  instrumentally. 

Footling  Presentation  is  the  most  Favorable. — The  details  of  the 
cases  in  which  the  feet  presented,  or  in  which  turning  was  performed, 
clearly  show  that  footling  presentation  was  by  far  the  most  favor- 
able, and  it  is  fortunate  the  feet  often  present  naturally.  The  infer- 
ence, of  course,  is,  that  version  should  be  resorted  to  whenever  any 
other  presentation  is  met  with  in  cases  of  double  monstrosity  of  this 
type ;  but,  unfortunately,  this  rule  could  rarely  be  carried  into  exe- 
cution, since  we  possess  no  means  of  diagnosing  the  junction  of  the 
foetuses  at  a  sufficiently  early  stage  of  labor  to  admit  of  turning  being 
performed.  It  is  only  under  exceptionably  favorable  circumstances 
that  this  can  be  done ;  as,  for  example,  in  a  case  recorded  by  Molas,1 
in  which  both  heads  presented,  but  neither  would  enter  the  brim  of 
the  pelvis. 

The  Chief  Difficulty  is  in  the  Delivery  of  the  Heads. — The  great  diffi- 
culty must  of  course  be  in  the  delivery  of  the  heads ;  for  in  all  the 
recorded  cases,  with,  one  exception,  the  bodies  have  passed  through 
the  pelvis  parallel  to  each  other  with  comparative  ease  until  the 
necks  have  appeared,  and  then,  as  a  rule,  they  could  be  brought  no 
farther.  It  is  clear  that  the  remainder  of  the  foetuses  could  no  longer 
pass  simultaneously ;  and,  were  direct  traction  continued,  the  heads 
would  be  inextricably  fixed  above  the  brim.  In  accordance  with 
the  direction  of  the  pelvic  axes  the  posterior  head  must  first  engage 
in  the  inlet ;  and-  in  order  to  effect  this,  it  will  be  necessary  to  carry 
the  bodies  of  the  children  well  over  the  abdomen  of  the  mother. 
This  seems  to  be  a  point  of  primary  importance.  It  would  also  be 
advisable  to  see  that  the  bodies  are  made  to  pass  through  the  pelvis 
with  their  backs  in  the  oblique  diameter.  By  this  means  more  space 
is  gained  than  if  the  backs  were  placed  antero-posteriorly  ;  while,  at 
the  same  time,  there  is  less  chance  of  the  heads  hitching  against  the 
promontory  of  the  sacrum  and  symphysis  pubis,  which  otherwise 
would  be  very  apt  to  occur. 

Mode  of  Delivery  when  the  Head  Presents. — When  the  head  pre- 
sents, and  the  labor  is  terminated  by  the  natural  powers,  delivery 
seems  to  be  accomplished  in  one  of  two  ways. 

In  the  first  and  more  common,  the  head  and  shoulders  of  one  child 
are  born,  its  breech  and  legs  being  subsequently  pushed  through  the 
pelvis  by  a  process  similar  to  that  of  spontaneous  evolution ;  and, 

1  Mem.  de  1' Academic,  vol.  i. 


300  LABOR. 

afterwards,  the  second  child  probably  passes  footling  without  much 
difficulty. 

Barkow  relates  a  case  in  which  loth  heads  were  delivered  by  the 
forceps,  the  bodies  subsequently  passing  simultaneously.  Two 
similar  instances  are  recorded  in  the  third  and  sixth  volumes  of  the 
"Obstetrical  Transactions."  When  delivery  takes  place  in  this 
manner,  the  head  of  the  second  child  must  lit  into  the  cavity  formed 
by  the  neck  of  the  first,  and  the  pelvis  must  necessarily  be  suffi- 
ciently roomy  to  admit  of  the  expulsion  of  the  head  of  the  second 
child,  while  its  cavity  is  diminished  in  size  by  the  presence  of  the 
neck  and  shoulders  of  the  first.  Either  of  these  processes  must  ob- 
viously require  exceptionally  favorable  conditions  as  regards  the  size 
of  the  child  and  the  pelvis ;  and  the  difficulty  in  the  way  of  delivery 
must  be  much  greater  than  when  the  lower  extremities  present. 
Therefore,  I  think  the  rule  should  be  laid  down  that,  when  the  nature 
of  the  case  is  made  out  (and  for  the  purpose  of  accurate  diagnosis  a 
complete  examination  under  anaesthesia  should  be  practised),  turning 
should  be  performed,  and  the  feet  brought  down. 

Mutilation  of  the  Foetuses. — In  the  event  of  its  being  found  impos- 
sible to  effect  delivery  after  a  considerable  portion  of  the  bodies  is 
born,  no  resource  remains  but  the  mutilation  of  the  body  of  one 
child,  so  as  to  admit  of  the  passage  of  the  other.  This  was  found 
necessary  in  one  case  in  which  the  children  presented  by  the  feet, 
and  were  born  as  far  as  the  thorax,  but  could  get  no  farther.  The 
body  of  the  anterior  child  was  removed  by  a  circular  incision  as  far 
as  it  had  been  expelled,  which  allowed  the  remaining  portion,  con- 
sisting of  the  head  and  shoulders,  to  re-enter  the  uterus ;  after  this 
the  posterior  child  was  easily  extracted,  and  the  mutilated  foetus 
followed  without  difficulty. 

Class  B. — In  class  B,  in  which  the  children  are  united  back  to 
back,  3  cases  are  recorded,  all  of  which  were  delivered  by  the  natural 
powers.  One  of  these  is  the  case  of  Judith  and  Helene,  the  celebrated 
Hungarian  twins,  who  lived  to  the  age  of  twenty-one.1  Helene  was 
born  as  far  as  the  umbilicus,  and.  after  the  lapse  of  three  hours,  her 
breech  and  legs  descended.  Judith  was  expelled  immediately  after- 
wards, her  feet  descending  first.  [The  celebrated  Carolina  twins 
born  July  11,  1851,  and  still  living,  were  brought  into  the  world  by 
the  same  method,  but  the  mother  having  a  large  pelvis,  "had  a  brief 
and  easy"  delivery.  The  larger  of  the  two  girls  also  came  first,  as 
in  the  Szony  case  of  1701.  These  twins  are  now  nearly  six  years 
older  than  the  Hungarian  sisters  were  at  death. — ED.]  Exactly  the 
same  process  occurred  in  a  case  described  by  M.  Norman,  the  children 
being  also  born  alive,  and  dying  on  the  ninth  day. 

Labor  is  easier  than  in  Class  A. — It  is  probable  that  labor  is  easier 
in  this  class  of  double  monsters  than  in  the  former,  because  the 
children  are  so  joined  that  there  is  no  necessity  for  the  bodies  to  be 
parallel  to  each  other  during  birth  when  the  head  presents,  and  after 
the  birth  of  the  head  and  shoulders  of  the  first  child,  its  breech  and 

1  Born,  Oct.  26,  1701;  died,  Feb.  8,  1723. 


DYSTOCIA    FKOM    F(ETUS.  361 

lower  extremities  are  evidently  pushed  down  and  expelled  by  a 
process  of  spontaneous  evolution.  If  the  feet  originally  presented, 
the  mechanism  of  delivery  and  the  rules  to  be  followed  would  be  the 
same  as  in  class  A;  but  the  difficulty  would  probably  be  greater, 
since  the  juncture  is  not  so  flexible,  and  a  more  complete  parallelism 
of  the  bodies  would  be  necessary  during  extraction. 

Class  G. — In  class  C,  that  of  the  dicephalous  monster,  I  have  found 
the  description  of  the  birth  of  8  cases,  3  of  which  were  terminated 
by  the  natural  powers.  In  two  of  these,  the  process  of  evolution 
was  the  main  agent  in  delivery;  one  head  being  born  and  becoming 
fixed  under  the  arch  of  the  pubis,  the  body  being  subsequently 
pushed  past  it,  and  the  second  head  following  without  difficulty. 
This  process  failing,  the  proper  course  is  to  decapitate  the  first  born 
head,  and  then  bring  down  the  feet  of  the  child,  when  deliverv  can 
be  accomplished  with  ease.  This  was  the  course  adopted  in  2  out 
of  the  8  cases;  and  it  may  be  done  with  the  less  hesitation,  since, 
from  their  structural  peculiarities,  it  is  extremely  improbable  that 
monsters  of  this  kind  should  survive.  In  the  third  case,  terminated 
naturally,  the  heads  were  said  to  have  been  born  simultaneously,  but 
it  seems  probable  that  the  one  head  lay  in  the  hollow  formed  by  the 
neck  of  the  other,  and  so  rapidly  followed  it.  If  the  feet  presented, 
the  case  may  be  managed  in  the  same  manner  as  in  class  A. 

Class  D. — Monstrosities  of  class  D,  in  which  the  heads  are  united, 
the  bodies  being  distinct,  appear  to  be  the  most  uncommon  of  all; 
and  I  can  find  the  description  of  delivery  in  only  2  cases.  One  of 
these  gave  rise  to  great  difficulty;  the  labor  in  the  other  was  easy. 
We  should  scarcely  anticipate  much  difficulty  in  the  birth  of  monsters 
of  this  type ;  for,  if  the  head  presented  and  would  not  pass,  we  should 
naturally  perform  craniotomy;  and  if  the  bodies  came  first,  the 
delivery  of  the  monstrous  head  could  readily  be  accomplished  by 
perforation. 

Result  to  the  Mothers. — The  result  to  the  mothers  in  all  these  cases 
seems  to  have  been  very  favorable.  There  is  only  one  in  which  the 
death  of  the  mother  is  recorded;  and  although  in  many  the  result  is 
not  mentioned,  we  may  fairly  assume  that  recovery  took  place. 

Among  difficulties  in  labor,  some  of  the  most  important  are  due  to 
morbid  conditions  of  the  foetus  itself. 

Intra-uterine  Hydrocephalus. — Of  these  the  most  common,  as  well 
as  the  most  serious,  is  caused  by  intra-uterine  hydrocephalus  (giving 
rise  to  a  collection  of  watery  fluid  within  the  cranium),  by  which  the 
dimensions  of  the  child's  head  are  enormously  increased,  and  the  due 
relations  between  it  and  the  pelvic  cavity  entirely  destroyed  (Fig. 
124). 

Its  Danger  loth  as  regards  the  Mother  and  Child. — Fortunately,  this 
disease  is  of  comparatively  rare  occurrence,  for  it  is  one  of  great 
gravity  both  as  regards  the  mother  and  child.  As  regards  the 
mother,  the  serious  character  of  the  complication  is  proved  by  the 
statistics  of  Dr.  Keiller,  of  Edinburgh,  who  found  that,  out  of  74 
cases,  no  less  than  16  were  accompanied  by  rupture  of  the  uterus. 
The  reason  of  the  danger  to  which  the  mother  is  subjected  is  obvious-. 
24 


362 


LABOR. 


In  some  few  cases,  indeed,  the  head  is  so  compressible  that,  provided 
the  amount  of  contained  fluid  be  small,  it  may  be  sufficiently  dimin- 
ished in  size,  by  the  moulding  to  which  it  is  subjected,  to  admit  of 
its  being  squeezed  through  the  pelvis.  In  the  majority  of  cases, 


FIG.  124. 


Labor  Impeded  by  Hydrocephalus. 

however,  the  size  of  the  head  is  too  great  for  this  to  occur.  The 
uterus  therefore  exhausts  itself,  and  may  even  rupture,  in  the  vain 
endeavor  to  overcome  the  obstacle;  while  the  large  and  distended 
head  presses  firmly  on  the  cervix,  or  on  the  pelvic  tissues,  if  the  os 
be  dilated,  and  all  the  evil  effects  of  prolonged  compression  are  apt 
to  follow. 

Its  Diagnosis  is  not  always  easy. — The  diagnosis  of  intra-uterine 
hydrocephalus  is  by  no  means  so  easy  as  the  description  in  obstetric 
works  would  lead  us  to  believe.  It  is  true  that  the  head  is  much 
larger  and  more  rounded  in  its  contour  than  the  healthy  foetal 
cranium,  and  also  that  the  sutures  and  fontanelles  are  more  wide, 
and  admit  occasionally  of  fluctuation  being  perceived  through  them. 
Still  it  is  to  be  remembered  that  the  head  is  always  arrested  above 
the  brim,  where  it  is  consequently  high  up  and  difficult  to  reach,  and 
where  these  peculiarities  are  made  out  with  much  difficulty.  As  a 
matter  of  fact,  the  true  nature  of  the  case  is  comparatively  rarely 
•discovered  before  delivery ;  thus  Chaussier1  found  that  in  more  than 
•one-half  of  the  cases  he  collected  an  erroneous  diagnosis  had  been 
.made. 

Method  of  Diagnosis. — Whenever  we  meet  with  a  case  in  which 
either  the  history  of  previous  labor,  or  a  careful  examination,  con- 
vinces us  that  there  is  no  obstacle  due  to  pelvic  deformity,  in  which 

1  Gazette  Medicale,  1864. 


DYSTOCIA    FROM    FCETUS.  363 

the  pains  are  strong  and  forcing,  but  in  which  the  head  persistently 
refuses  to  engage  in  the  brim,  we  may  fairly  surmise  the  existence 
of  hydrocephalus.  Nothing,  however,  short  of  a  careful  examination 
under  anaesthesia,  the  whole  hand  being  passed  into  the  vagina  so  as 
to  explore  the  presenting  part  thoroughly,  will  enable  us  to  be  quite 
sure  of  the  existence  of  this  complication.  Under  these  circum- 
stances such  a  complete  examination  is  not  only  justified  but  impera- 
tive ;  and,  when  it  has  been  made,  the  difficulties  of  diagnosis  are 
lessened,  for  then  we  may  readily  make  out  the  large  round  mass, 
softer  and  more  compressible  than  the  healthy  head,  the  widely  sepa- 
rated sutures,  and  the  fluctuating  fontanelles. 

Pelvic  Presentations  are  frequently  met  with. — In  a  considerable 
proportion  of  cases — as  many,  it  is  said,  as  1  out  of  5 — the  foetus 
presents  by  the  breech.  The  diagnosis  is  then  still  more  difficult ; 
for  the  labor  progresses  easily  until  the  shoulders  are  born,  when  the 
head  is  completely  arrested,  and  refuses  to  pass  with  any  amount  of 
traction  that  is  brought  to  bear  on  it.  Even  the  most  careful  exami- 
nation may  not  now  enable  us  to  make  out  the  cause  of  the  delay, 
for  the  finger  will  impinge  on  the  comparatively  firm  base  of  the 
skull,  and  may  be  unable  to  reach  the  distended  portion  of  the 
cranium.  At  this  time  abdominal  palpation  might  throw  some  light 
on  the  case,  for  the  uterus  being  tightly  contracted  round  the  head, 
we  might  be  able  to  make  out  its  unusual  dimensions.  The  wasted 
and  shrivelled  appearance  of  the  child's  body,  which  so  often  accom- 
panies hydrocephalus,  would  also  arouse  suspicion  as  to  the  cause  of 
delay.  On  the  whole  such  cases  may  be  fairly  assumed  to  be  less 
dangerous  to  the  mother  than  when  the  head  presents ;  for,  in  the 
latter,  the  soft  parts  are  apt  to  be  subjected  to  prolonged  pressure 
and  contusion ;  while  in  the  former,  delay  does  not  commence  till 
after  the  shoulders  are  born,  and  then  the  character  of  the  obstacle 
would  be  sooner  discovered,  and  appropriate  means  earlier  taken  to 
overcome  it. 

Treatment. — The  treatment  is  simple,  and  consists  in  tapping  the 
head,  so  as  to  allow  the  cranial  bones  to  collapse.  There  is  the  less 
objection  to  this  course,  since  the  disease  almost  necessarily  precludes 
the  hope  of  the  child's  surviving.  The  aspirator  would  draw  off  the 
fluid  effectually,  and  would  at  least  give  the  child  a  chance  of  life  ; 
and,  under  certain  circumstances,  the  birth  of  a  child,  who  lives  for 
a  short  time  only,  may  be  of  extreme  legal  importance.  More  gene- 
rally the  perforator  will  be  used,  and  as  soon  as  it  has  penetrated,  a 
gush  of  fluid  will  at  once  verify  the  diagnosis.  Schroeder  recom- 
mends that,  after  perforation,  turning  should  be  performed,  on  account 
of  the  difficulty  with  which  the  flaccid  head  is  propelled  through  the 
pelvis.  This  seems  a  very  unnecessary  complication  of  an  already 
sufficiently  troublesome  case.  As  a  rule,  when  once  the  fluid  has 
been  evacuated,  the  pains  being  strong,  as  they  generally  are,  no 
delay  need  be  apprehended.  Should  the  head  not  come  down,  the 
cephalotribe  may  be  applied,  which  takes  a  firmer  grasp  than  the 
forceps,  and  enables  the  head  to  be  crushed  to  a  very  small  size  and 
readily  extracted. 


364  LABOR. 

Treatment  when  the  Breech  Presents. — "When  the  breech  presents, 
the  head  must  be  perforated  through  the  occipital  bone,  and  gene- 
rally this  may  be  accomplished  behind  the  ear  without  much  diffi- 
culty. It  has  been  said  that  opening  of  the  vertebral  canal  might 
allow  the  intra-cranial  fluid  to  escape,  but  I  am  not  aware  that  the 
suggestion  has  ever  been  carried  into  practice. 

Other  forms  of  dropsical  elision  may  give  rise  to  some  difficulty, 
but  by  no  means  so  serious.  In  a  few  rare  cases  the  thorax  has 
been  so  distended  with  fluid  as  to  obstruct  the  passage  of  the  child. 
Ascites  is  somewhat  more  common;  and,  occasionally,  the  child's 
bladder  is  so  distended  with  urine  as  to  prevent  the  birth  of  the 
body.  The  existence  of  any  of  these  conditions  is  easily  ascertained ; 
for  the  head  or  breech,  whichever  happens  to  present,  is  delivered 
without  difficulty,  and  then  the  rest  of  the  body  is  arrested.  This 
will  naturally  cause  the  practitioner  to  make  a  careful  exploration, 
when  the  cause  of  the  delay  will  be  detected. 

The  treatment  consists  in  the  evacuation  of  the  fluid  by  puncture. 
In  the  case  of  ascites,  this  should  always  be  done,  if  possible,  by  a 
fine  trocar  or  aspirator,  so  as  not  to  injure  the  child.  This  is  all  the 
more  important  since  it  is  impossible  to  distinguish  a  distended 
bladder  from  ascites,  and  an  opening  of  any  size  into  that  viscus 
might  prove  fatal,  whereas  aspiration  would  do  little  or  no  harm, 
and  would  prove  quite  as  efficacious. 

Fcetal  Tumors  Obstructing  Delivery. — Certain  foetal  tumors  may 
occasion  dystocia,  such  as  malignant  growths,  or  tumors  of  the 
kidney,  liver,  or  spleen.  Cases  of  this  kind  are  recorded  in  most 
obstetric  works.  Hydro-encephacele,  or  hydro-rachitis,  depending 
on  defective  formation  of  the  cranial  or  spinal  bones,  with  the  for- 
mation of  a  large  protruding  bag  of  fluid,  is  not  very  rare.  The 
diagnosis  of  all  such  cases  is  somewhat  obscure,  nor  is  it  possible  to 
lay  down  any  definite  rules  for  their  management,  which  must  vary 
according  to  the  particular  exigencies.  The  tumors  are  rarely  of 
sufficient  size  to  prove  formidable  obstacles  to  delivery,  and  many  of 
them  are  very  compressible.  This  is  especially  the  case  with  spina 
bifida  and  similar  cystic  growths.  Puncture,  and  in  the  more  solid 
growths  of  the  abdomen  or  thorax,  evisceration,  may  be  required. 

Other  Congenital  Deformities. — Other  deformities,  such  as  the  anen- 
cephalous  foetus,  or  defective  development  of  the  thorax  or  abdominal 
parietes  with  protrusion  of  the  viscera,  are  not  likely  to  cause  any 
difficulty;  but  they  may  much  embarrass  the  diagnosis  by  the  strange 
and  unusual  presentation  that  is  felt.  If,  in  any  case  of  doubt,  a  full 
and  careful  examination  be  undertaken,  introducing  the  whole  hand 
if  necessary,  no  serious  mistake  is  likely  to  be  made. 

Dystocia  from  Excessive  Development  of  the  Foetus. — In  addition  to 
dystocia  from  morbid  conditions  of  the  foetus,  difficulties  may  arise 
from  its  undue  development,  and  especially  from  excessive  size  and 
advanced  ossification  of  the  skull.  This  last  is  especially  likely  to 
cause  delay.  Even  the  slight  difference  in  size  between  the  male 
and  female  head  was  found  by  Simpson  to  have  an  appreciable  effect 
in  increasing  the  difficulty  of  labor,  when  the  statistics  of  a  large 


DYSTOCIA    FROM    FCETUS.  365 

number  of  cases  were  taken  into  account;  for  lie  proved  beyond 
doubt  that  the  difficulties  and  casualties  of  labor  occurred  in  de- 
cidedly larger  proportion  in  male  than  in  female  births.  Other  cir- 
cumstances, besides  sex,  have  an  important  effect  on  the  size  of  the 
child.  Thus  Duncan  and  Hecker  have  shown  that  it  increases  in 
proportion  to  the  age  of  the  mother  and  the  frequency  of  the  labors, 
while  the  size  of  the  parents  has  no  doubt  also  an  important  bearing 
on  the  subject. 

Although  these  influences  modify  the  results  of  labor  en  masse, 
they  have  little  or  no  practical  bearing  on  any  particular  case,  since 
it  is  impossible  to  estimate  either  the  size  of  the  head,  or  the  degree 
of  its  ossification,  until  labor  is  advanced. 

Its  Treatment. — When  labor  is  retarded  by  undue  ossification  or 
large  size  of  the  head,  the  case  must  be  treated  on  the  same  general 
principles  which  guide  us  when  the  want  of  proportion  is  caused  by 
pelvic  contraction.  Hence,  if  delay  arise,  which  the  natural  powers 
are  insufficient  to  overcome,  it  will  seldom  happen  that  the  dispro- 
portion is  too  great  for  the  forceps  to  overcome.  If  we  fail  to  de- 
liver by  it,  no  resource  is  left  but  perforation. 

Large  Size  of  the  Body  rarely  causes  Delay. — Large  size  of  the 
body  of  the  child  is  still  more  rarely  a  cause  of  difficulty,  for,  if  the 
head  be  born,  the  compressible  trunk  will  almost  always  follow. 
Still,  a  few  authentic  cases  are  on  record,  in  which  it  was  found  im- 
possible to  extract  the  foetus  on  account  of  the  unusual  bulk  of  its 
shoulders  and  thorax.  Should  the  body  remain  firmly  impacted 
after  the  birth  of  the  head,  it  is  easy  to  assist  its  delivery  by  traction 
on  the  axilla3,  by  gently  aiding  the  rotation  of  the  shoulders  into  the 
antero-posterior  diameter  of  the  pelvic  cavity,  and,  if  necessary,  by 
extracting  the  arms,  so  as  to  lessen  the  bulk  of  the  part  of  the  body 
contained  in  the  pelvis.  Hicks  relates  a  case  in  which  evisceration 
was  required  for  no  other  apparent  reason  than  the  enormotfs  size  of 
the  body.  The  necessity  for  any  such  extreme  measure  must,  of 
course,  be  of  the  greatest  possible  rarity;  and  it  is  quite  exceptional 
for  difficulty  from  this  source  to  be  beyond  the  powers  of  nature  to 
overcome. 


366  LABOR. 


CHAPTER  XII. 

DEFORMITIES  OF   THE    PELVIS. 

DEFORMITIES  of  the  pelvis  form  one  of  the  most  important  sub- 
jects of  obstetric  study,  for  from  them  arise  some  of  the  gravest 
difficulties  and  clangers  connected  with  parturition.  A  knowledge, 
therefore,  of  their  causes  and  effects,  and  of  the  best  mode  of  de- 
tecting them,  either  during  or  before  labor,  is  of  paramount  necessity ; 
but  the  subject  is  far  from  easy,  and  it  has  been  rendered  more  diffi- 
cult than  it  need  be,  from  over-anxiety  on  the  part  of  obstetricians 
to  force  all  varieties  of  pelvic  deformities  within  the  limits  of  their 
favorite  classification. 

Difficulties  of  Classification. — Many  attempts  in  this  direction  have 
been  made,  some  of  which  are  based  on  the  causes  on  which  the 
deformities  depend,  others  on  the  particular  kind  of  deformity  pro- 
duced. The  changes  of  form,  however,  are  so  various  and  irregular, 
and  similar,  or  apparently  similar,  causes  so  constantly  produce  dif- 
ferent effects,  that  all  such  endeavors  have  been  more  or  less  unsuc- 
cessful. For  example,  we  find  that  rickets  (of  all  causes  of  pelvic 
deformity  the  most  important)  generally  produces  a  narrowing  of 
the  conjugate  diameter  of  the  brim;  while  the  analogous  disease, 
osteo-malacia,  occurring  in  adult  life,  generally  produces  contraction 
of  the  transverse  diameter,  with  approximation  of  the  pubic  bones, 
and  relative  or  actual  elongation  of  the  conjugate  diameter.  AVe 
might,  therefore,  be  tempted  to  classify  the  results  of  these  two 
diseases  under  separate  heads,  did  we  not  find  that,  when  rickets 
affects  children  who  are  running  about,  and  subject  to  mechanical 
influences  similar  to  those  acting  upon  patients  suffering  from  osteo- 
malacia,  a  form  of  pelvis  is  produced  hardly  distinguishable  from  that 
met  with  in  the  latter  disease. 

Most  Simple  Classification. — On  the  whole,  therefore,  the  most 
simple,  as  well  as  the  most  scientific,  classification  is  that  which  takes 
as  its  basis  the  particular  seat  and  nature  of  the  deformity.  Let  us 
first  glance  at  the  most  common  causes. 

Causes  of  Pelvic  Deformity. — The  key  to  the  particular  shape  as- 
sumed by  a  deformed  pelvis  will  be  found  in  a  knowledge  of  the  cir- 
cumstances which  lead  to  its  regular  development  and  normal  shape 
in  a  state  of  health.  The  changes  produced  may,  almost  invariably, 
be  traced  to  the  action  of  the  same  causes  which  produce  a  normal 
pelvis,  but  which,  under  certain  diseased  conditions  of  the  bones  or* 
articulations,  induce  a  more  or  less  serious  alteration  in  form.  These 
have  been  already  described  in  discussing  the  normal  anatomy  of  the 
pelvis,  and  it  will  be  remembered  that  they  are  chiefly  the  weight  of 
the  body,  transmitted  to  the  iliac  bones  through  the  sacro-iliac  joints, 


DEFORMITIES    OF    THE    PELVIS.  307 

and  counter-pressure  on  these,  acting  through  the  acetabula.  Some- 
times they  act  in  excess  on  bones  which  are  healthy,  but  possibly 
smaller  than  usual,  and  the  result  may  be  the  formation  of  certain 
abnormalities  in  the  size  of  the  various  pelvic  diameters.  At  other 
times  they  operate  on  bones  which  are  softened  and  altered  in  texture 
by  disease,  and  which,  therefore,  yield  to  the  pressure  far  more  than 
healthy  bones. 

The  two  diseases  which  chiefly  operate  in  causing  deformity  arc 
rickets  and  osteo-malacia.  Into  the  essential  nature  and  symptoma- 
tology of  these  complaints  it  would  be  out  of  place  to  enter  here ;  it 
may  suffice  to  remind  the  reader  that  they  are  believed  to  be  patho- 
logically similar  diseases,  with  the  important  practical  distinction 
that  the  former  occurs  in  early  life  before  the  bones  are  completely 
ossified,  and  that  the  latter  is  a  disease  of  adults  producing  softening 
in  bones  that  have  been  hardened  and  developed.  This  difference 
affords  a  ready  explanation  of  the  generally  resulting  varieties  of 
pelvic  deformity. 

Effects  of  Rickets. — Rickets  commences  very  early  in  life,  some- 
times, it  is  believed,  even  in  utero.  It  rarely  produces  softening  of 
the  entire  bones,  and  only  in  cases  of  very  great  severity  of  those 
parts  of  the  bones  that  have  been  already  ossified.  The  effects  of  the 
disease  are  principally  apparent  in  the  cartilaginous  portions  of  the 
bones,  in  which  osseous  deposit  has  not  yet  taken  place.  The  bones, 
therefore,  are  not  subject  to  uniform  change,  and  this  fact  has  an 
important  influence  in  determining  their  shape.  Rickety  children 
also  have  imperfect  muscular  development ;  they  do  not  run  about 
in  the  same  way  as  other  children,  they  are  often  continuously  in  the 
recumbent  or  sitting  postures,  and  thus  the  weight  of  the  trunk  is 
brought  to  bear,  more  than  in  a  state  of  health,  on  the  softened  bones. 
For  the  same  reason  counter-pressure  through  the  acetabula  is  absent 
or  comparatively  slight.  When,  however,  the  disease  occurs  for  the 
first  time  in  children  who  are  able  to  run  about,  the  latter  comes  into 
operation,  and  modifies  the  amount  and  nature  of  the  deformity.  It 
is  to  be  observed  that  in  rickety  children  the  bones  are  not  only 
altered  in  form,  from  pressure,  but  are  also  imperfectly  developed, 
and  this  materially  modifies  the  deformity.  When  ossific  matter  is 
deposited,  the  bones  become  hard  and  cease  to  bend  under  external 
influences,  and  retain  forever  the  altered  shape  they  have  assumed. 

Effects  of  Osteo-malacia. — In  osteo-malacia,  on  the  contrary,  the 
already  hardened  bones  become  softened  uniformly  through  all  their 
textures,  and  thus  the  changes  which  are  impressed  upon  them  are 
much  more  regular,  and  more  easily  predicated.  It  is,  however,  an 
infinitely  less  common  cause  of  pelvic  deformity  than  rickets,  as  is 
evidenced  by  the  fact  that  in  the  Paris  Maternity  in  a  period  of  sixteen 
years,  402  cases  of  deformity  due  to  rickets  occurred  to  1  due  to 
osteo-malacia.1 

Their  varying  Frequency, — The  frequency  of  both  diseases  varies 
greatly  in  different  countries,  and  under  different  circumstances. 

1  Stanesco,  Recherches  Cliniques  sur  les  Retr6cissements  du  Bassin. 


3G8  LABOR. 

Rickets  is  much  more  common  amongst  the  poor  of  large  cities, 
whose  children  are  ill-fed,  badly  clothed,  kept  in  a  vitiated  atmo- 
sphere, and  subjected  to  unfavorable  hygienic  conditions.  Deformi- 
ties are,  therefore,  more  common  in  them  than  in  the  more  healthy 
children  of  the  upper  classes,  or  of  the  rural  population.1  The  higher 
degrees  of  deformity,  necessitating  the  Cossarean  section,  or  crani- 
otomy,  are  in  this  country  of  extreme  rarity  ;  while,  in  certain  districts 
on  the  Continent,  they  seem  to  be  so  frequent  that  these  ultimate 
resources  of  the  obstetric  art  have  to  be  constantly  employed. 

Effects  of  Ossification  of  Pelvic  Articulations. — In  another  class  of 
cases  the  ordinary  shape  is  modified  by  weight  and  counter-pressure 
operating  on  a  pelvis  in  which  one  or  more  of  the  articulations  is 
ossified.  In  this  way  we  have  produced  the  obliquely  ovate  pelvis  of 
Naegele,  or  the  still  more  uncommon  transversely  contracted  pelvis  of 
Eobert. 

Other  Causes  of  Pelvic  Deformity. — A  certain  number  of  deformed 
pelves  cannot  be  referred  to  a  modification  of  the  ordinary  develop- 
mental changes  of  the  bones.  Amongst  these  are  the  deformities 
resulting  from  spondylolithesis,  or  downward  dislocation  of  the  lower 
lumbar  vertebrae ;  from  displacements  of  the  sacrum,  produced  by 
curvatures  of  the  spinal  column  ;  or  from  diseases  of  the  pelvic  bones 
themselves,  such  as  tumors,  malignant  growths,  and  the  like. 

Equally  Enlarged  Pelvis. — The  first  class  of  deformed  pelves  to  be 
considered  is  that  in  which  the  diameters  are  altered  from  the  usual 
standard,  without  any  definite  distortion  of  the  bones ;  and  such  are 
often  mere  congenital  variations  in  size,  for  which  no  definite  expla- 
nation can  be  given.  Of  this  class  is  the  pelvis  which  is  equally 
enlarged  in  all  its  diameters  (pelvis  sequabiliter  justo  major),  which  is 
of  no  obstetric  consequence,  except  insomuch  as  it  may  lead  to  pre- 
cipitate labor,  and  is  not  likely  to  be  diagnosed  during  life. 

Equally  Contracted  Pelvis. — The  corresponding  diminution  of  all 
the  pelvic  diameters  (pelvis  sequabiliter  justo  minor)  may  be  met  with 
in  women  who  are  apparently  well  formed  in  every  respect,  and 
whose  external  conformation  and  previous  history  give  no  indica- 
tion of  the  abnormality.  Sometimes  the  diminution  amounts  to 
half  an  inch  or  more,  and  it  can  readily  be  understood  that  such  a 
lessening  in  the  capacity  of  the  pelvis  would  give  rise  to  serious 
difficulty  in  labor.  Thus,  in  3  cases  recorded  by  Naegele  a  fatal  re- 
sult followed ;  in  2  after  difficult  instrumental  delivery,  and  in  the 
third  after  rupture  of  the  uterus.  The  equally  lessened  pelvis,  how- 
ever, is  of  great  rarity.  An  unusually  small  pelvis  may  be  met  with 
in  connection  with  general  small  size,  as  in  dwarfs.  It  does  not 
necessarily  follow,  because  a  woman  is  a  dwarf,  that  the  pelvis  is  too 
small  for  parturition.  On  the  contrary,  many  such  women  have 
borne  children  without  difficulty. 

The  Undeveloped  Pelvis. — In  some  cases  a  pelvis  retains  its  in- 
fantile characteristics  after  puberty  (Fig.  125).  The  normal  develop- 

'[These  appear  to  be  more  common  amonjr  the  blacks  of  Alabama  and  Louisiana, 
than  any  other  part  of  our  population  ;  and  in  these  States  the  Caesarean  operation 
has  been  the  most  frequently  performed  of  any  in  the  Union. — ED.] 


DEFORMITIES    OF    THE    PELVIS.  369 

ment  of  the  pelvis  has  been  interfered  with,  possibly  from  premature 
ossification  of  the  different  portions  of  the  innominate  bones,  or  from 
arrest  of  their  growth  by  a  weakly  or  rachitic  constitution.  The 
measurements  of  these  pelves  are  not  always  below  the  normal 
standard,  they  may  continue  to  grow,  although  they  have  not  de- 
veloped. The  proportionate  measurements  of  the  various  diameters 

FIG.  125. 


Adult  Pelvis  Retaining  its  Infantile  Type. 

will  then  be  as  in  the  infant ;  and  the  antero-posterior  diameter  may 
be  longer,  or  as  long,  as  the  transverse,  the  ischia  comparatively 
near  each  other,  and  the  pubic  arch  narrow.  Such  a  form  of  pelvis 
will  interfere  with  the  mechanism  of  delivery,  and  unusual  difficulty 
in  labor  will  be  experienced.  Difficulties  from  a  similar  cause  may 
be  expected  in  very  young  girls.  Here,  however,  there  is  reason  to 
hope  that,  as  age  advances,  the  pelvis  will  develop,  and  subsequent 
labors  be  more  easy. 

Masculine  or  Funnel-shaped  Pelvis.— The  masculine,  or  funnel- 
shaped  pelvis  owes  its  name  to  its  approximation  to  the  type  of  the 
male  pelvis.  The  bones  are  thicker  and  stouter  than  usual,  the  con- 
jugate diameter  of  the  brim  longer,  and  the  whole  cavity  rendered 
deeper  and  narrower  at  its  lower  part  by  the  nearness  of  the  ischial 
tuberosities.  It  is  generally  met  with  in  strong  muscular  women 
following  laborious  occupations,  and  Dr.  Barnes,  from  his  experience 
in  the  Koyal  Maternity  Charity,  says  that  it  chiefly  occurs  in  weavers 
in  the  neighborhood  of  Bethnal  Green,  who  spend  most  of  their 
time  in  the  sitting  posture.  "  The  cause  of  this  form  of  pelvis  seems 
to  be  an  advanced  condition  of  ossification  in  a  pelvis  which  would 
otherwise  have  been  infantile,  brought  about  by  the  development 
of  unusual  muscularity,  corresponding  to  the  laborious  employment 
of  the  individual."  The  difficulties  in  labor  will  naturally  be  met 
with  towards  the  outlet,  where  the  funnel  shape  of  the  cavity  is  most 
apparent. 


370  LABOR. 

Contraction  of  Conjugate  Diameter  of  Brim. — Diminution  of  the 
antero-posterior  diameter  is  most  frequently  limited  to  the  brim,  and 
is  by  far  the  most  common  variety  of  pelvic  deformity.  In  its 
slighter  degrees  it  is  not  necessarily  dependent  on  rickets,  although 
when  more  marked  it  almost  invariably  is  so.  When  unconnected 
with  rickets,  it  probably  can  be  traced  to  some  injurious  influence 
before  the  bones  have  ossified,  such  as  increased  pressure  of  the  trunk 
from  carrying  weights  in  early  childhood,  and  the  like.  By  this 
means  the  sacrum  is  unduly  depressed,  and  projects  forwards,  so  as 
to  slightly  narrow  the  conjugate  diameter. 

Mode  of  production  in  Rickets. — When  caused  by  rickets  the  amount 
of  the  contraction  varies  greatly,  sometimes  being  very  slight,  some- 
times sufficient  to  prevent  the  passage  of  the  child  altogether,  and 
necessitate  craniotomy  of  the  Caesarean  section.  The  sacrum,  softened 
by  the  disease,  is  pressed  vertically  downwards  by  the  weight  of  the 
body,  its  descent  being  partially  resisted  by  the  already  ossified  por- 
tions of  the  bone,  so  that  the  result  is  a  downward  and  forward 
movement  of  the  promontory.  The  upper  portion  of  the  sacral  con- 
cavity is  thus  directed  more  backwards;  but,  as  the  apex  of  the 
bone  is  drawn  forwards  by  the  attachment  of  the  perineal  muscles 
to  the  coccyx,  and  by  the  sacro-ischiatic  ligaments,  a  sharp  curve  of 
its  lower  part  in  a  forward  direction  is  established. 

Occasional  Increase  of  Transverse  Diameter. — The  depression  of  the 
sacral  promontory  would  tend  to  produce  strong  traction,  through 
the  sacro-iliac  ligaments,  on  the  posterior  ends  of  the  sacro-cotyloid 
beams,  and  thus  induce  expansion  of  the  iliac  bones,  and  consequent 
increase  of  the  transverse  diameter  of  the  brim.  So  an  unusual 
length  of  the  transverse  diameter  is  very  often  described  as  accom- 
panying this  deformity,  but  probably  it  is  not  so  often  apparent  as 
might  otherwise  be  expected,  on  account  of  the  imperfect  develop- 
ment of  the  bones  generally  accompanying  rickets ;  and  Barnes1  .-ays 
that  in  the  parts  of  London  where  deformities  are  most  rife,  any 
enlargement  of  the  transverse  diameter  is  exceedingly  rare.  Fre- 
quently the  sacrum  is  not  only  depressed,  but  displaced  more  or  less 
to  one  side,  most  generally  to  the  left,  thus  interfering  with  the 
regular  shape  of  the  deformed  brim.  This  is  often  the  result  of  a 
lateral  flexion  of  the  spinal  column,  depending  on  the  rachitic  dia- 
thesis. 

Cavity  of  Pelvis  is  generally  not  Affected. — In  most  cases  of  this 
kind  the  cavity  of  the  pelvis  is  not  diminished  in  size,  and  is  often 
even  more  than  usually  wide.  The  constant  pressure  on  the  ischia, 
which  the  sitting  posture  of  the  child  entails,  tends  to  force  them 
apart,  and  also  to  widen  the  pubic  arch.  Considerable  advantage 
results  from  this  in  cases  in  which  we  have  to  perform  obstetric  ope- 
rations, as  it  gives  plenty  of  room  for  manipulation. 

Figure-of-eiyht  Deformity. — In  a  few  exceptional  cases  the  narrow- 
ing of  the  conjugate  diameter  is  increased  by  a  backward  depression 
of  the  symphysis  pubis,  which  gives  the  pelvic  brim  a  sort  of  figure- 

1  Lectures  on  Obst.  Operations,  p.  280 


DEFORMITIES    OF    THE    PELVIS. 


371 


of-eiglit  shape  (Fig.  126).  The  most  reasonable  explanation  of  this 
peculiarity  seems  to  be,  that  it  is  the  result  of  the  muscular  contrac- 
tion of  the  recti  muscles,  at  their  point  of  attachment,  when  the 
centre  of  gravity  of  the  body  is  thrown  backwards,  on  account  of 


FIG.  12C. 


Rickety  Pelvis,  with  backward  depression  of  the  Symphysis  Pubis. 

the  projection  of  the  sacral  promontory.  Sometimes  also  the  antero- 
posterior  diameter  of  the  cavity  is  unusually  lessened  by  the  disap- 
pearance of  the  vertical  curvature  of  the  sacrum,  which,  instead  of 
forming  a  distinct  cavity,  is  nearly  flat  (Fig.  127). 

FIG.  127. 


Flatness  of  Sacrum  with  Narrowing  of 
Pelvic  Cavity. 


Pelvis  Deformed  by  Spondylolithe-is. 
(After  Kilian.) 


Spondyloli thesis. — In  a  few  rare  cases,  to  which  attention  was  first 
called  in  1853  by  Kilian  of  Bonn,  a  very  formidable  narrowing  of 
the  conjugate  diameter  of  the  pelvic  brim  is  produced  by  a  down- 
ward displacement  of  the  fourth  and  fifth  lumbar  vertebrae,  which 
become  dislocated  forward,  or  if  not  actually  dislocated,  at  least 
separated  from  their  several  articulations  to  a  sufficient  extent  to 
encroach  very  seriously  on  the  dimensions  of  the  pelvic  inlet.  This 
condition  is  known  as  spondylolithesis.  (Fig.  128.) 


372  LABOR. 

The  effect  of  this  is  sufficiently  obvious,  for  the  projection  of  the 
lumbar  vertebras  prevents  the  passage  of  the  child.  To  such  an  extent 
is  obstruction  thus  produced,  that,  in  the  majority  of  the  recorded 
cases,  the  Ciesarean  section  was  necessary.  The  true  conjugate  diam- 
eter, that  between  the  promontory  of  the  sacrum  and  the  symphysis 
pubis,  is  increased  rather  than  diminished ;  but,  for  all  practical  pur- 
poses, the  condition  is  similar  to  extreme  narrowing  of  the  conjugate 
from  rickets,  for  the  bodies  of  the  displaced  vertebras  project  into 
and  obstruct  the  pelvic  brim. 

The  cause  of  this  deformity  seems  to  be  different  in  different  cases. 
In  some  it  seems  to  have  been  congenital,  and  in  others  to  have  de- 
pended on  some  antecedent  disease  of  the  bones,  such  as  tuberculosis 
or  scrofula,  producing  inflammation  and  softening  of  the  connection 
between  the  last  lumbar  vertebra  and  the  sacrum,  thus  permitting 
downward  displacement  of  the  bones.  Lambl  believed  that  it  gene- 
rally followed  spina  bifida,  which  had  become  partially  cured,  but 
which  had  produced  deformity  of  the  vertebrae,  and  favored  their 
dislocation.  Brodhurst,1  on  the  other  hand,  thinks  that  it  most  prob- 
ably depends  on  rachitic  inflammation  and  softening  of  the  osseous 
and  ligamentous  structures,  and  that  it  is  not  a  dislocation  in  the 
strict  sense  of  the  word. 

Narrowing  of  the  Oblique  Diameter. — [This  disease  is  so  rare  in  the 
United  States,  that  it  is  not  recorded  in  a  single  instance,  as  a  cause 
for  gastro-hysterotomy. — ED.]  The  most  marked  examples  of  nar- 
rowing of  both  oblique  diameters  depend  on  osteo-malacia.  In  this 
disease,  as  has  already  been  remarked,  the  bones  are  uniformly  soft- 
ened; and  the  alterations  in  form  are  further  influenced  by  the  fact 
that  the  disease  commences  after  union  of  the  separate  portions  of 
the  os  innominaturn  has  been  completely  effected.  The  amount  of 
deformity  in  the  worst  cases  is  very  great,  and  frequently  renders 
delivery  impossible  without  the  Csesarean  section.  Sometimes  the 
softening  of  the  bones  proves  of  service  in  delivery,  by  admitting  of 
the  dilatation  of  the  contracted  pelvic  diameter  by  the  pressure  of  the 
presenting  part,  or  even  by  the  hand.  Some  curious  cases  are  on 
record  in  which  the  deformity  was  so  great  as  to  apparently  require 
the  Caesarean  section,  but  in  which  the  softened  bones  eventually 
yielded  sufficiently  to  render  this  unnecessary. 

Mode  of  Production  in  Osteo-malacia. — The  weight  of  the  body  de- 
presses the  sacrum  in  a  vertical  direction,  and  at  the  same  time 
compresses  its  component  parts  together,  so  as  to  approximate  the 
base  and  apex  of  the  bone,  and  narrow  the  conjugate  diameter  of 
the  brim,  by  causing  the  promontory  to  encroach  upon  it.  The  most 
characteristic  changes  are  produced  by  the  pushing  inwards  of  the 
walls  of  the  pelvis  at  the  cotyloid  cavities,  in  consequence  of  pressure 
exerted  at  these  points  through  the  femurs.  The  effect  of  this  is  to 
diminish  both  oblique  diameters,  giving  the  brim  somewhat  the 
shape  of  a  trefoil,  or  an  ace  of  clubs.  The  sides  of  the  pubis  are  at 
the  same  time  approximated,  and  may  become  almost  parallel,  and 

1  Obst.  Trans.,  vol.  vi.  p.  97. 


DEFORMITIES    OF    THE    PELVIS. 


373 


the  true  conjugate  may  be  even  lengthened  (Fig.  129).  The  tuberosities 
of  the  ischia  are  also  compressed  together,  with  the  rest  of  the  lateral 


Osteo-malacic  Pelvis. 


pelvic  wall,  so  that  the  outlet  is  greatly  deformed  as  well  as  the  brim 
(Fig.  130). 

FIG.  130. 


Extreme  Degree  of  Osteo-malacic  Deformity. 

Obliquely  Contracted  Pelvis. — That  form  of  deformity  in  which  ane 
oblique  diameter  only  is  lessened,  has  received  considerable  attention, 
from  having  been  made  the  subject  of  special  study  by  Naegele,  and 
is  generally  known  as  the  obliquely  contracted  pelvis  (Fig.  131).  It  is 
a  condition  that  is  very  rarely  met  with,  although  it  is  interesting 
from  an  obstetric  point  of  view,  as  throwing  considerable  light  on 
the  mode  in  which  the  natural  development  of  the  pelvis  is  effected. 
It  is  difficult  to  diagnose,  inasmuch  as  there  is  no  apparent  external 
deformity,  and  probably  it  has  never,  in  fact,  been  detected  before 
delivery.  It  has  a  very  serious  influence  on  labor ;  Litzmann  found 
that  out  of  28  cases  of  this  deformity,  22  died  in  their  first  labors, 


374  LABOR. 

and  5  more  in  subsequent  deliveries.  The  prognosis,  therefore,  is 
very  formidable,  and  renders  a  knowledge  of  this  distortion,  rare 
though  it  be,  of  much  importance. 

Its  essential  characteristic  is  flattening  and  want  of  development 
of  one  side  of  the  pelvis,  associated  with  anchylosis  of  the  corre- 
sponding   sacro-iliac    synchondrosis. 
FIG.  131.  The  latter  is  probably  always  present, 

and  it  seems  to  be  most  generally  a 
congenital  malformation.  The  lateral 
half  of  the  sacrum  on  the  same  side, 
and  the  entire  innominate  bone  are 
much  atrophied.  The  promontory  of 
the  sacrum  is  directed  towards  the 
diseased  side,  and  the  symphysis  pubis 
is  pushed  over  towards  the  healthy 
side. 

The  main  agent  in  the  production 
of  this  deformity  is  the  absence  of  the 
obliquely  contracted  Pelvis.   (After        sacro-iliac  joint,  which  prevents  the 
Dnncan.)  proper  lateral  expansion  of  the  pelvic 

brim   on   that  side,  and   allows  the 

counter-pressure,  through  the  femur,  to  push  in  the  atrophied  os 
innominatum  to  a  much  greater  extent  than  usual.  The  chief  dimi- 
nution in  the  length  of  the  pelvic  diameter  is  between  the  ilio-pec- 
tineal  eminence  of  the  affected  side  and  the  healthy  sacro-iliac  joint ; 
while  the  oblique  diameter  between  the  anchylosed  joint  and  the 
healthy  os  innominatum  is  of  normal  length. 

Narrowing  of  the  Transverse  Diameter. — Transverse  contraction  ot 
the  pelvic  brim  is  very  much  less  common  than  narrowing  of  the 
conjugate  diameter.  It  most  frequently  depends  on  backward  cur- 
vature of  the  lower  parts  of  the  spinal  column,  in  consequence  of 
disease  of  the  vertebrae.  This  form  of  deformed  pelvis  is  generally 
known  as  the  ky photic.  The  effect  of  the  spinal  curvature  is  to  drag 
the  promontory  of  the  sacrum  backwards,  so  that  it  is  high  up  and 
out  of  reach.  By  this  means  the  antero-posterior  diameter  of  the 
brim  is  increased,  while  the  transverse  is  lessened ;  the  relative  pro- 
portion between  the  two  is  thus  reversed.  While  the  upper  propor- 
tion of  the  sacrum  is  displaced  backwards,  its  lower  end  is  projected 
forward,  so  that  the  antero-posterior  diameters  of  the  cavity  and 
outlet  are  considerably  diminished.  The  ischial  tuberosities  are  also 
nearer  to  each  other,  and  the  pubic  arch  is  narrowed.  Obstruction 
to  delivery  will  be  chiefly  met  with  at  the  lower  parts  and  outlet  of 
the  pelvic  cavity;  for,  although  the  transverse  diameter  of  the  brim 
is  narrowed,  there  is  generally  sufficient  space  for  the  passage  of  the 
head. 

RoberCs  Pelvis. — Another  form  of  transversely  contracted  pelvis 
is  known  as  Robert's  pelvis  (Fig.  132),  having  been  first  described  by 
Robert,  of  Coblentz.  It  is  in  fact  a  double  obliquely  contracted 
pelvis,  depending  on  anchylosis  of  both  sacro-iliac  joints,  and  conse- 
quent defective  development  of  the  innominate  bones.  The  shape 


DEFORMITIES    OF    THE    PELVIS. 


375 


FIG.  132. 


Robertas  or  Double  Obliquely  Contracted 
Pelvis.     (After  Duncan.) 


of  the  pelvic  brim  is  markedly  oblong,  and  the  sides  of  the  pelvis 
are  more  or  less  parallel  with  each  other.  The  outlet  is  also  much 
contracted  transversely.  The  amount 
of  obstruction  is  very  great,  so  that, 
according  to  Schroeder,  out  of  7  well- 
authenticated-  cases  the  Caesarean 
section  was  required  in  6. 

Deformity  from  Old-standing  Hip- 
joint  Disease. — -Another  cause  of 
transverse  deformity,  occasionally 
met  with,  is  luxation  of  the  head  of 
the  femur,  depending  on  old-standing 
joint  disease.  The  head  of  the  femur, 
in  this  case,  presses  on  the  innominate 
bone  at  the  site  of  dislocation,  and 
the  result  is  that  the  iliac  fossa  on 
the  aft'ected  side,  or  both  if  the  acci- 
dent happens  on  both  sides,  is  pushed  inwards,  the  transverse  diam- 
eter of  the  brim  being  lessened.  The  tuberosity  of  the  ischium  is, 
however,  projected  outwards,  so  that  the  outlet  of  the  pelvis  is 
increased  rather  than  diminished. 

Deformity  from  Tumors,  Fractures,  etc. — Obstruction  of  the  pelvic 
cavity  from  exostosis  or  other  forms  of  tumors  growing  from  the 
bones  is  of  great  rarity  (Fig.  133). 
It  may,  however,  produce  very 
serious  dystocia.  Several  curious 
examples  are  collected  in  Mr.  Wood's 
article  on  the  pelvis,  in  some  of  which 
the  obstruction  was  so  great  as  to 
necessitate  the  Caesarean  section.1 
Some  of  these  growths  were  true 
exostoses;  others  osteo-sarcomatous 
tumors  attached  to  the  pelvic  bones, 
most  generally  the  upper  part  of  the 
sacrum ;  and  others  were  malignant. 
In  some  cases  spiculae  of  bone  have 
developed  about  the  linea  ilio-pec- 
tinea  or  other  parts  of  the  pelvis, 
which  may  not  be  sufficient  to  pro- 
duce obstruction,  but  which  may 
injure  the  uterus,  or  even  the  foetal 

head,  when  they  are  pressed  upon      Bony  Growth  from  Sacruni  obstructing  the 
them.      Irregular   projections   may  Pelvic  cavity, 

also  arise   from   the   callus   of  old 

fractures  of  the  pelvic  bones.     All  such  cases  defy  classification,  and 
differ  so  greatly  in  their  extent,  and  in  their  effect  on  labor,  that  no 


FIG.  133. 


['  Eight  women  having  pelvic  exostoses  have  been  operated  upon  by  Ctesarean 
section  in  the  United  States,  with  four  recoveries. — ED.] 


376  LABOR. 

rules  can  be  laid  down  for  them,  and  each  must  be  treated  on  its  own 
merits. 

Effects  of  Contracted  Pelvis  in  Labor. — The  effects  of  pelvic  con- 
tractions on  labor  vary,  of  course,  greatly  with  the  amount  and 
nature  of  the  deformity ;  but  they  must  always  give  rise  to  anxiety, 
and,  in  the  graver  degrees,  they  produce  the  most  serious  difficulties 
we  have  to  contend  with  in  the  whole  range  of  obstetrics. 

Nature  of  Uterine  Action  in  Pelvic  Deformity. — In  the  lesser  degrees, 
in  which  the  proportion  between  the  presenting  part  and  the  pelvis 
is  only  slightly  altered,  we  may  observe  little  abnormal  beyond  a 
greater  intensity  of  the  pains,  and  some  protraction  of  the  labor.  It 
is  generally  observed  that  the  uterine  contractions  are  strong  and 
forcible  in  cases  of  this  kind,  probably  because  of  the  increased 
resistance  they  have  to  contend  against;  and  this  is  obviously  a 
desirable  and  conservative  occurrence,  which  may,  of  itself,  suffice 
to  overcome  the  difficulty.  The  first  stage,  however,  is  not  infre- 
quently prolonged,  and  the  pains  are  ineffective,  for  the  head  does 
not  readily  engage  in  the  brim,  the  uterus  is  more  mobile  than  in 
ordinary  labors,  and  it  probably  acts  at  a  disadvantage. 

Risk  to  the  Mother. — In  the  more  serious  cases,  the  mother  is  sub- 
jected to  many  risks,  directly  proportionate  to  the  amount  of  obstruc- 
tion and  the  length  of  the  labor.  The  long- continued  and  excessive 
uterine  action,  produced  by  the  vain  endeavors  to  push  the  child 
through  the  contracted  pelvic  canal,  the  more  or  less  prolonged  con- 
tusion and  injury  to  which  the  maternal  soft  parts  are  necessarily 
subjected  (not  unfrequently  ending  in  inflammation  and  sloughing 
with  all  its  attendant  dangers),  and  the  direct  injury  which  may  be 
inflicted  by  the  measures  we  are  compelled  to  adopt  for  aiding  de- 
livery (such  as  the  forceps,  turning,  crauiotomy,  or  Cnesarean  section), 
all  tend  to  make  the  prognosis  a  matter  of  grave  anxiety. 

Risk  to  the  Child. — Nor  are  the  dangers  less  to  the  child ;  and  a 
very  large  proportion  of  still-births  will  always  be  met  with.  The 
infantile  mortality  may  be  traced  to  a  variety  of  causes,  the  most 
important  being  the  protraction  of  the  labor,  and  the  continuous 
pressure  to  which  the  presenting  part  is  subjected.  For  this  reason, 
even  in  cases  in  which  the  contraction  is  so  slight  that  the  labor  is 
terminated  by  the  natural  powers,  it  has  been  estimated  that  1  out 
of  every  5  children  is  still-born;  and  as  the  deformity  increases  in 
amount,  so,  of  course,  does  the  prognosis  to  the  child  become  more 
unfavorable. 

Frequent  Occurrence  of  Prolapse  of  the  Cord. — Prolapse  of  the 
umbilical  cord  is  of  very  frequent  occurrence  in  cases  of  pelvic  de- 
formity, the  tendency  to  this  accident  being  traceable  to  the  fact  of 
the  head  not  entering  and  occupying  the  upper  strait  of  the  pelvis 
as  in  ordinary  labors,  and  thus  leaving  a  space  through  which  the 
cord  may  descend.  So  frequently  is  this  complication  met  with  in 
pelvic  deformity  that  Stanesco1  found  it  had  happened  as  often  as  59 
times  in  414  labors ;  and  when  the  dangers  of  prolapsed  funis  are 

1  Op.  cit.  p.  94. 


DEFORMITIES    OF    THE    PELVIS.  377 

added  to  those  of  protracted  labors,  it  is  hardly  a  matter  of  surprise 
that  the  occurrence  should,  under  such  circumstances,  almost  always 
prove  fatal  to  the  child. 

Injury  to  Child's  Head. — The  head  of  the  child  is  also  liable  to 
injury  of  a  more  or  less  grave  character  from  the  compression  to 
which  it  is  subjected,  especially  by  the  promontory  of  the  sacrum. 
Independently  of  the  transient  effects  of  undue  pressure  (temporary 
alteration  of  the  shape  of  the  bones  and  bruising  of  the  scalp),  there 
is  often  met  with  a  more  serious  depression  of  the  bones  of  the  skull, 
produced  by  the  sacral  promontory.  This  is  most  marked  in  cases 
in  which  the  head  has  been  forcibly  dragged  past  the  projecting  bone 
by  the  forceps,  or  after  turning.  The  amount  of  depression  varies 
with  the  degree  of  contraction ;  but  sometimes,  were  it  not  for  the 
yielding  of  the  bones  of  the  foetal  skull  in  this  way,  delivery,  with- 
out lessening  the  size  of  the  head  by  perforation,  would  be  impossi- 
ble. Such  depressions  are  found  at  the  spot  immediately  opposite 
the  promontory,  generally  at  the  side  of  the  skull  near  the  junction 
of  the  frontal  and  parietal  bones.  Sometimes  there  is  a  slight  per- 
manent mark,  but  more  often  the  depression  disappears  in  a  few 
days.  The  prognosis  to  the  child  is,  however,  grave,  when  the  con- 
traction has  been  sufficient  to  indent  the  skull ;  for  it  has  been  found 
that  50  per  cent,  of  the  children  thus  marked  died  either  immediately 
or  shortly  after  labor.1 

Course  of  Labor. — The  means  which  nature  takes  to  overcome  these 
difficulties  are  well  worthy  of  study,  and  there  are  certain  peculiar- 
ties  in  the  mechanism  of  delivery  when  pelvic  deformities  exist, 
which  it  is  of  importance  to  understand,  as  they  guide  us  in  deter- 
mining the  proper  treatment  to  adopt. 

Frequency  of  Malpresentation. — Malpresentations  of  the  foetus  are 
of  much  more  frequent  occurrence  than  in  ordinary  labors ;  partly 
because  the  head  does  not  engage  readily  in  the  brim,  but,  remaining 
free  above  it,  is  apt  to  be  pushed  away  by  the  uterine  contractions  ; 
and  partly  because  of  the  frequent  alteration  of  the  axis  of  the 
uterine  tumor.  The  pendulous  condition  of  the  abdomen  in  cases 
of  pelvic  deformity  is  often  very  obvious,  so  that  the  fundus  is 
sometimes  almost  in  a  line  with  the  cervix,  and  thus  transverse  or 
other  abnormal  positions  are  very  frequently  met  with.  It  is  to  be 
noted,  however,  that  we  cannot  regard  breech  presentations  as  so 
unfavorable  as  in  ordinary  labors,  for  the  pressure  from  the  con- 
tracted pelvis  is  less  likely  to  be  injurious  when  applied  to4he  body 
than  to  the  head  of  the  child ;  and  indeed,  as  we  shall  presently  see, 
the  artificial  production  of  these  presentations  is  often  advisable  as  a 
matter  of  choice. 

Mechanism  of  Delivery  in  Head  Presentations. — The  mode  in  which 
the  head  passes  naturally  through  a  contracted  pelvis  is  in  some  re- 
spects different  from  the  ordinary  mechanism  of  delivery  in  head 
presentations,  and  has  been  carefully  worked  out  by  Spiegelberg, 
and  other  Grerman  obstetricians. 

1  Schroeder,  op.  cit.  p.  256. 
25 


878  LABOR. 

The  means  which  nature  adopts  to  overcome  the  difficulty  are  dif- 
ferent in  cases  in  which  there  is  a  marked  narrowing  of  the  conju- 
gate diameter  of  the  brim,  and  in  those  in  which  there  is  a  generally 
contracted  pelvis. 

In  Contracted  Brim. — In  the  former,  and  more  common  deformity, 
when  the  head  enters  the  brim,  in  consequence  of  the  resistance  it 
meets  with,  the  expelling  power  of  the  uterus  acts  more  on  the  ante- 
rior part  of  the  head  than  in  ordinary  cases,  the  chin  becomes  in 
some  degree  separated  from  the  sternum,  and  the  anterior  fontanelle 
descends  somewhat  lower  than  the  posterior.  At  this  stage,  on  ex- 
amination, it  will  be  found — supposing  we  have  to  do  with  a  case  in 
which  the  occiput  points  to  the  left  side  of  the  pelvis — that  the  inte- 
rior fontanelle  is  lower  than  the  posterior,  and  to  the  right,  the  bi- 
temporal  diameter  of  the  head  is  engaged  in  the  conjugate  diameter 
of  the  brim  (as  the  smallest  diameter  of  the  skull,  there  is  manifest 
advantage  in  this),  the  bi-parietal  diameter  and  the  largest  portion 
of  the  head  points  to  the  left  side.  The  sagittal  suture  will  be  felt 
running  across  in  the  transverse  diameter  of  the  brim,  but  nearer  to 
the  sacrum,  the  head  being  placed  obliquely.  As  the  head  is  forced 
down  by  the  uterine  contractions,  the  parietal  bone,  which  is  resting 
on  the  promontory,  is  pushed  against  it,  so  that  the  sagittal  suture 
is  forced  more  into  the  true  transverse  diameter  of  the  pelvic  brim, 
and  approaches  nearer  to  the  pubis.  The  next  step  is  the  depression 
of  the  head,  the  occiput  undergoing  a  sort  of  rotation  on  its  trans- 
verse axis,  so  that  it  reaches  a  plane  below  the  brim.  When  this  is 
accomplished,  the  rest  of  the  head  readily  passes  the  obstruction. 
The  forehead  now  meets  with  the  resistance  of  the  pelvic  walls,  the 
posterior  fontanelle  descends  to  a  lower  level,  and,  as  the  cavity  of 
the  pelvis  in  cases  of  antero-posterior  contraction  of  the  brim  is 
generally  of  normal  dimensions,  the  rest  of  the  labor  is  terminated 
in  the  usual  way. 

In  generally  Contracted  Pelvis. — In  the  generally  contracted  pelvis 
the  head  enters  the  brim  with  the  posterior  fontanelle  lowest,  and  it 
is  after  it  has  engaged  in  it  that  the  resistance  to  its  progress  becomes 
manifest.  The  result  is,  therefore,  an  exaggeration  of  what  is  met 
with  in  ordinary  cases.  The  resistance  to  the  anterior  or  longer  arm 
of  the  lever  is  greater  than  that  to  the  occipital  or  shorter ;  and, 
therefore,  the  flexion  of  the  head  becomes  very  marked.  The  pos- 
terior fontanelle  is  consequently  unusually  depressed,  and  the  ante- 
rior quite  out  of  reach.  So  the  head  is  forced  down  as  a  wedge,  and 
its  further  progress  must  depend  upon  the  amount  of  contraction. 
If  this  be  not  too  great  the  anterior  fontanelle  eventually  descends, 
and  delivery  is  completed  in  the  usual  way.  Should  the  contraction 
be  too  much  to  permit  of  this,  the  head  becomes  jammed  in  the 
pelvis,  and  diminution  of  its  size  may  be  essential. 

In  cases  of  deformity  of  the  conjugate  diameter,  combined  with 
general  contraction  of  the  pelvis,  the  mechanism  partakes  of  the  pe- 
culiarities of  both  these  classes,  to  a  greater  or  less  extent,  in  pro- 
portion to  the  preponderance  of  one  or  other  species  of  deformity. 


DEFORMITIES    OF    THE    PELVIS.  379 

Diagnosis. — -It  rarely  happens  that  deformities  of  the  pelvis,  ex- 
cept of  the  gravest  kind,  are  suspected  before  labor  has  actually 
commenced ;  and,  therefore,  we  are  not  often  called  upon  to  give  an 
opinion  as  to  the  condition  of  the  pelvis  before  delivery.  Should 
we  be  so,  there  are  various  circumstances  which  may  aid  us  in  ar- 
riving at  a  correct  conclusion.  Prominent  among  them  is  the  history 
of  the  patient  in  childhood.  If  she  is  known  to  have  suffered  from 
rickets  in  early  life,  more  especially  if  the  disease  has  left  evident 
traces  in  deformities  of  the  limbs,  or  in  a  dwarfed  and  stunted  growth, 
or  in  curvature  of  the  spine,  there  will  be  strong  presumptive  evi- 
dence of  pelvic  deformity ;  a  markedly  pendulous  state  of  the  abdo- 
men may  also  tend  to  confirm  the  suspicion.  Nothing  short  of  a 
careful  examination  of  the  pelvis  itself  will,  however,  clear  up  the 
point  with  certainty ;  and,  even  by  this  means,  to  estimate  the  pre- 
cise degree  of  deformity  with  accuracy  requires  considerable  skill 
and  practice.  The  ingenuity  of  practitioners  has  been  much  exer- 
cised, it  might  perhaps  be  justly  said,  wasted,  in  the  invention  of 
various  more  or  less  complicated  pelvimeters  for  aiding  us  in  obtain- 
ing the  desired  object.  It  is,  however,  pretty  generally  admitted  by 
all  accoucheurs,  that  the  hand  forms  the  best  and  most  reliable  in- 
strument for  this  purpose,  at  any  rate  as  regards  the  interior  of  the 
pelvis;  although  a  pair  of  callipers,  such  as  Baudelocque's  well-known 
instrument,  is  essential  for  accurately  determining  the  external  meas- 
urements. The  objections  to  all  internal  pelvimeters,  even  those  most 
simple  in  their  construction,  are  their  cost  and  complexity,  and  the 
impossibility  of  using  them  without  pain  or  injury  to  the  patient. 

External  Measurements. — It  was  formerly  thought  that  by  measur- 
ing the  distance  between  the  spinous  processes  of  the  sacrum  and  the 
symphysis  pubis,  and  subtracting  from  it  what  we  judge  to  be  the 
thickness  of  the  bones  and  soft  parts,  we  might  arrive  at  an  approxi- 
mate estimate  of  the  measurement  of  the  conjugate  diameter  of  the 
pelvic  brim.  It  is  now  admitted  that  this  method  can  never  be  de- 
pended on,  and  that  it  is  practically  useless.  [In  a  case  of  rachitic 
deformity  where  the  conjugate  diameter  measured  2J  inches,  the  ex- 
ternal sacro-pubic  measurement  was  an  inch  over  the  normal. — ED.] 
A  change  in  the  relative  length  of  other  external  measurements  of 
the  pelvis  is,  however,  often  of  great  value  in  showing  the  existence 
of  deformity  internally,  although  not  in  judging  of  its  amount.  The 
measurements  which  are  used  for  this  purpose  are  between  the 
anterior  superior  spines  of  the  ilia,  and  between  the  centres  of  their 
crests,  averaging  respectively  9J  and  10|  inches.  According  to 
Spiegelberg  these  measurements  may  give  one  of  three  results. 

1.  Both  may  be  less  than  they  ought  to  be,  but  the  relation  of  the 
one  to  the  other  remains  unchanged. 

2.  That  between  the  crests  is  not,  or  is  at  most  very  little,  dimin- 
ished, but  that  between  the  spines  is  increased. 

3.  Both  are  diminished,  but  at  the  same  time  their  mutual  relation 
is  not  normal,  the  distance  between  the  spines  being  as  long,  if  not 
longer,  than  that  between  the  crests. 


380 


LABOR. 


FlG.   134. 


No.  1  denotes  a  uniformly  contracted  pelvis.  No.  2,  a  pelvis 
simply  contracted  in  the  conjugate  diameter  of  the  brim,  and  not 
otherwise  deformed.  No.  3,  a  pelvis  with  narrowed  conjugate  and 
also  uniformly  contracted,  as  in  the  severe  type  of  rachitic  de- 
formity. 

Besides  tlie  above  some  information  may  be  obtained  by  the 
measurement  of  the  external  conjugate  diameter,  which  averages 
7f  inches.  This  may  be  taken  by  placing  one  point  of  the  callipers 
in  the  depression  below  the  spine  of  the  last  lumbar  vertebra,  the 
other  at  the  centre  of  the  upper  edge  of  the  symphysis  pubis.  If  the 
measurement  be  distinctly  below  the  average,  we  may  conclude  that 
there  is  a  narrowing  of  the  antero-posterior  diameter  of  the  brim, 
the  extent  of  which  we  must  endeavor  to  ascertain  by  other  means. 
For  the  purpose  of  making  these  measurements  Baudelocque's 
compas  d1  epaisseur  can  be  used,  or  Dr.  Lazarewitch's  elegant  universal 
pelvimeter,  which  can  be  adopted  also  for  internal  pelvimetry  ;  but, 
in  the  absence  of  these  special  contrivances,  an  ordinary  pair  of  calli- 
pers, such  as  are  used  by  carpenters,  can  be  made  to  answer  the 
desired  object. 

Internal  Measurements. — These  external  measurements  must  be 
corroborated  by  internal,  chiefly  of  the  antero-posterior  diameter,  by 

wrhich  alone  we  can  estimate  the 
amount  of  the  deformity.  We  en- 
deavor to  find,  in  the  first  place,  the 
length  of  the  diagonal  conjugate, 
between  the  lower  edge  of  the  sym- 
physis pubis  and  the  promontory 
of  the  sacrum,  which  averages 
about  half  an  inch  more  than  the 
true  conjugate.  The  patient  lying 
in  the  usual  obstetric  position,  or 
still  better  lying  transversely  across 
the  bed,  with  her  hips  raised,  an 
attempt  is  made  to  reach  the  pro- 
montory of  the  sacrum  with  the  tip 
of  the  index  finger.  In  a  healthy 
pelvis  this  is  impossible,  so  that 
the  mere  fact  of  our  being  able  to 
do  so  proves  the  existence  of 
contraction.  A  mark  is  made 
with  the  nail  of  the  index  of  the 
left  hand  on  that  part  of  the  ex- 
amining finger  which  rests  under 
the  symphysis,  and  then  the  dis- 
tance from  this  to  the  tip  of  the  finger,  less  half  an  inch,  may 
be  taken  to  indicate  the  measurement  of  the  true  conjugate  of  the 
brim.  Various  pelvimeters  are  meant  to  make  the  same  measure- 
ments, such  as  Lumley  Earle's,  Lazarewitch's,  which  is  similar  in 
principle,  and  Van  Huevel's;  the  best  and  simplest,  I  think,  is 
that  invented  by  Dr.  Greenhalgh  (Fig.  134).  It  consists  of  a  mov- 


Greenhalgh's  Pelvimeter. 


DEFORMITIES    OF    THE    PELVIS.  381 

able  rod,  attached  to  a  flexible  band  of  metal  which  passes  around 
the  palm  of  the  examining  hand.  At  the  distal  end  of  the  rod 
is  a  curved  portion,  which  passes  over  the  radial  edge  of  the 
index  finger.  The  examination  is  made  in  the  usual  way,  and  when 
the  point  of  the  finger  is  resting  on  the  promontory  of  the  sacrum, 
the  rod  is  withdrawn  until  it  is  arrested  by  the  posterior  surface  of 
the  symphysis,  the  exact  measurement  of  the  diagonal  conjugate 
being  then  read  off  on  the  scale. 

It  is  to  be  remembered  that  this  procedure  is  useless  in  the  slighter 
degrees  of  contraction,  in  which  the  promontory  of  the  sacrum  cannot 
be  reached.  Dr.  Ramsbotham  proposed  to  measure  the  conjugate  by 
spreading  out  the  index  and  middle  fingers  internally,  the  tip  of  one 
resting  on  the  promontory,  the  other  behind  the  symphysis  pubis; 
and  then  withdrawing  them,  in  the  same  position,  and  measuring  the 
distance  between  them.  This  manoeuvre  I  believe  to  be  impracticable. 

Whenever,  in  actual  labor,  we  wish  to  ascertain  the  condition  of 
the  pelvis  accurately,  the  patient  should  be  anaesthetized,  and  the 
whole  hand  introduced  into  the  vagina  (which  could  not  otherwise 
be  done  without  causing  great  pain),  and  the  proportions  of  the 
pelvis,  and  the  relations  of  the  head  to  it,  thoroughly  explored ;  and, 
if  what  has  been  said  as  to  the  mechanism  of  delivery  in  these  cases 
be  borne  in  mind,  this  may  aid  us  in  determining  the  kind  of  de- 
formity existing.  In  this  way  contractions  about  the  outlet  of  the 
pelvis  can  also  be  pretty  generally  made  out. 

Mode  of  Diagnosing  the  Oblique  Pelvis. — The  obliquely  contracted 
pelvis  cannot  be  determined  by  any  of  these  methods,  but  certain 
external  measurements,  as  Naegele  has  pointed  out,  will  readily 
enable  us  to  recognize  its  existence.  It  will  be  found  that  measure- 
ments, which  in  the  healthy  pelvis  ought  to  be  equal,  are  unequal  in 
the  obliquely  distorted  pelvis.  The  points  of  measurement  are  chiefly : 
1.  From  the  tuberosity  of  the  ischium  on  one  side  to  the  posterior 
superior  spine  of  the  ilium  on  the  other;  2.  From  the  anterior 
superior  iliac  spine  on  the  one  side  to  the  posterior  superior  on  the 
opposite;  3.  From  the  trochanter  major  of  one  side  to  the  posterior 
superior  iliac  spine  on  the  other;  4.  From  the  lower  edge  of  the 
symphysis  pubis  to  the  posterior  superior  iliac  spine;  5.  From  the 
spinous  process  of  the  last  lumbar  vertebra  to  the  anterior  superior 
spine  of  the  ilium  on  either  side. 

If  these  measurements  differ  from  each  other  by  half  an  inch  to  an 
inch,  the  existence  of  an  obliquely  deformed  pelvis  may  be  safely 
diagnosed.  The  diagnosis  can  be  corroborated  by  placing  the  patient 
in  the  erect  position,  and  letting  fall  two  plumb  lines,  one  from  the 
spines  of  the  sacrum,  the  other  from  the  symphysis  pubis.  In  a 
healthy  pelvis  these  will  fall  in  the  same  plane,  but  in  the  oblique 
pelvis  the  anterior  line  will  deviate  considerably  towards  the  un- 
affected side. 

Treatment. — The  proper  management  of  labor  in  contracted  pelvis 
is,  even  up  to  this  time,  one  of  the  most  vexed  questions  in  midwifery, 
notwithstanding  the  immense  amount  of  discussion  to  which  it  has 
given  rise;  and  the  varying  opinions  of  accoucheurs  of  equal  expe- 


382  LABOR. 

rience  afford  a  strong  proof  of  the  difficulties  surrounding  the  subject 
This  remark  applies,  of  course,  only  to  the  lesser  degrees  of  deformity, 
in  which  the  birth  of  a  living  child  is  not  hopeless.  When  the  antero- 
posterior  diameter  of  the  brim  measures  from  2f  to  3  inches,  it  is 
universally  admitted  that  the  destruction  of  the  child  is  inevitable, 
unless  the  pelvis  be  so  small  as  to  necessitate  the  performance  of  the 
Caesarean  section.  But  when  it  is  between  3  inches  and  the  normal 
measurement,  the  comparative  merits  of  the  forceps,  turning,  and 
the  induction  of  premature  labor,  form  a  fruitful  theme  for  discus- 
sion. With  one  class  of  accoucheurs  the  forceps  is  chiefly  advocated, 
and  turning  admitted  as  an  occasional  resource  when  it  has  failed ; 
and  this  indeed,  speaking  broadly,  may  be  said  to  have  been  the 
general  view  held  in  this  country.  More  recently  we  find  German 
authorities  of  eminence,  such  as  Schroeder  and  Spiegelberg,  giving 
turning  the  chief  place,  and  condemning  the  forceps  altogether  in 
contracted  pelvis,  or,  at  least,  restricting  its  use  within  very  narrow 
limits.  More  strangely  still  we  find,  of  late,  that  the  induction  of 
premature  labor,  on  the  origination  and  extension  of  which  British 
accoucheurs  have  always  prided  themselves,  is  placed  without  the 
pale,  and  spoken  of  as  injurious  and  useless  in  reference  to  pelvic 
deformities.  To  see  our  way  clearly  amongst  so  many  conflicting 
opinions  is  by  no  means  an  easy  task,  and  perhaps  we  may  best  aid 
in  its  accomplishment  by  considering  separately  the  three  operations 
in  so  far  as  they  bear  on  this  subject,  and  pointing  out  briefly  what 
can  be  said  for  and  against  each  of  them. 

The  Forceps. — In  England  and  in  France  it  is  pretty  generally 
admitted  that  in  the  slighter  degrees  of  contraction  the  most  reliable 
means  of  aiding  the  patient  is  by  the  forceps.  It  should  be  remem- 
bered that  the  operation,  under  such  circumstances,  is  always  much 
more  serious  than  in  ordinary  labors  simply  delayed  from  uterine 
inertia,  when  there  is  ample  room,  and  the  head  is  in  the  cavity  of 
the  pelvis ;  for  the  blades  have  to  be  passed  up  very  high,  often  when 
the  head  is  more  or  less  movable  above  the  brim,  and  much  more 
traction  is  likely  to  be  required.  For  these  reasons  artificial  assist- 
ance, when  pelvic  deformity  is  suspected,  is  not  to  be  lightly  or 
hurriedly  resorted  to.  Nor  fortunately  is  it  always  necessary ;  for 
if  the  pains  be  sufficiently  strong,  and  the  contraction  not  too  great 
to  prevent  the  head  engaging  at  all,  after  a  lapse  of  time  it  will  be- 
come so  moulded  in  the  brim  as  to  pass  even  a  considerable  obstruc- 
tion. In  all  cases,  therefore,  sufficient  time  must  be  given  for  this ; 
and  if  no  suspicious  symptoms  exist  on  the  part  of  the  mother — no 
elevation  of  temperature,  dryness  of  the  vagina,  rapid  pulse,  and  the 
like,  and  the  fcetal  heart-sounds  continue  to  be  normal — labor  may 
be  allowed  to  go  on  for  some  hours  after  the  rupture  of  the  mem- 
branes, so  as  to  give  nature  a  chance  of  completing  the  delivery. 
When  this  seems  hopeless,  the  intervention  of  art  is  called  for. 

Cases  Suitable  for  the  Forceps. — The  forceps  is  generally  considered 
to  be  applicable  in  all  degrees  of  contraction,  from  the  standard 
measurement,  down  to  about  3J  inches  in  the  conjugate  of  the  brim. 


DEFORMITIES    OF    THE    PELVIS.  383 

There  can  be  no  doubt  that,  in  such  cases,  traction  with  the  forceps 
often  enables  us  to  effect  delivery,  when  the  natural  efforts  have 
proved  insufficient,  and  holds  out  a  very  fair  hope  of  saving  the 
child.  Out  of  17  cases  in  which  the  high  forceps  operation  was  re- 
sorted to  for  pelvic  deformity,  reported  by  Stanesco,  in  13  living 
children  were  born.  If  the  length  of  the  labor,  and  the  long-con- 
tinued compression  to  which  the  child  has  been  subjected,  be  borne 
in  mind,  this  result  must  be  considered  very  favorable. 

Objections  that  have  been  raised  to  the  Forceps. — What  are  the  ob- 
jections which  have  been  brought  against  the  operation?  These  have 
been  principally  made  by  Schroeder  and  other  German  writers. 
They  are,  chiefly  the  difficulty  in  passing  the  instrument ;  the  risk 
of  injuring  the  maternal  structures  ;  and  the  supposition  that,  as  the 
blades  must  seize  the  head  by  the  forehead  and  occiput,  their  com- 
pressive  action  will  diminish  its  longitudinal  and  increase  its  trans- 
verse diameter  (which  is  opposed  to  the  contracted  part  of  the  brim), 
and  so  enlarge  the  head  just  where  it  ought  to  be  smallest.  There 
is  little  doubt  that  these  writers  much  exaggerate  the  compressive 
power  of  the  forceps.  Certainly  with  those  generally  used  in  this 
country,  any  disadvantage  likely  to  accrue  from  this  is  more  than 
counterbalanced  by  the  traction  on  the  head  ;  and  the  fact,  that 
minor  degrees  of  obstruction  can  be  thus  overcome,  with  safety  both 
to  the  mother  and  child,  is  abundantly  proved  by  the  numberless 
cases  in  which  the  forceps  have  been  used. 

It  is  not  equally  Suitable  in  all  kinds  of  Deformity. — It  is  very  likely 
that  the  forceps  do  not  act  equally  well  in  all  cases.  When  the  head 
is  loose  above  the  brim  ;  when  the  contraction  is  chiefly  limited  to 
the  antero-posterior  diameter,  and  there  is  abundance  of  room  at  the 
sides  of  the  pelvis  for  the  occiput  to  occupy  after  version ;  and  when, 
as  is  usual  in  these  cases,  the  anterior  fontanelle  is  depressed  and  the 
head  lies  transversely  across  the  brim,  it  is  probable  that  turning 
may  be  the  safer  operation  for  the  mother,  and  the  easier  performed. 
When,  on  the  other  hand,  the  head  has  engaged  in  the  brim,  and  has 
become  more  or  less  impacted,  it  is  obvious  that  version  could  not  be 
performed  without  pushing  it  back,  which  may  neither  be  easy  nor 
safe.  In  the  generally  contracted  pelvis,  in  which  the  head  enters  in 
an  exaggerated  state  of  flexion  and  lies  obliquely,  the  posterior  fon- 
tanelle being  much  depressed,  the  forceps  are  more  suitable. 

Mechanical  Advantage  of  Turning  in  certain  .  Cases. — The  special 
reasons  why  version  sometimes  succeeds  when  the  forceps  fails,  or 
why  it  may  be  elected  from  the  first  as  a  matter  of  choice,  have  been 
by  no  one  better  pointed  out  than  by  Sir  James  Simpson.  Although 
the  operation  was  performed  by  many  of  the  older  obstetricians,  its 
revival  in  modern  times,  and  the  clear  enunciation  of  its  principles, 
can  undoubtedly  be  traced  to  his  writings.  He  points  out  that  the 
head  of  the  child  is  shaped  like  a  cone,  its  narrowest  portion  the 
base  of  the  cranium  (Fig.  135,  bb),  measuring,  on  an  average,  from 
J  to  f  of  an  inch  less  than  the  broadest  portion  (Fig.  135,  aa),  viz., 
the  bi-parietal  diameter.  In  ordinary  head  presentations  the  latter 


LABOR. 


FlG.  135. 


Section  of  Foetal  Cranium,  show- 
ing its  Conical  Form. 

FIG.  136. 


part  of  the  head  has  to  pass  first;  but  if  the  feet  are  brought  down, 
the  narrow  apex  of  the  cranial  cone  is  brought  first  into  apposition 
with  the  contracted  brim,  and  can  be  more 
easily  draivn  through  than  the  broader  base 
can  be  pushed  through  by  the  uterine  con- 
tractions. Nor  is  this  the  only  advantage, 
for  after  turning  the  narrower  bi-temporal 
diameter  (Fig.  136,  bb) — which  measures,  on 
an  average,  half  an  inch  less  than  the  bi- 
parietal  (Fig.  136,  aa) — is  brought  into  con- 
tact with  the  contracted  conjugate,  while  the 
broader  bi-parietal  lies  in  the  comparatively 
wide  space  at  the  side  of  the  pelvis  (Fig.  137). 
These  mechanical  considerations  are  suffici- 
ently obvious,  and  fully  explain  the  success 
which  has  often  attended  the  performance  of 
the  operation. 

Limits  of  the  Operation. — It  is  generally 
admitted  that  it  may  be  possible,  for  the  rea- 
sons just  mentioned,  to  deliver  a  living  child 
by  turning,  through  a  pelvis  contracted  be- 
yond the  point  which  would  permit  of  a  living 
child  being  extracted  by  the  forceps.  Many 
obstetricians  believe  that  it  is  possible  to  de- 
liver a  living  child  by  turning  in  a  pelvis 
contracted  even  to  the  extent  of  2f  inches  in 
the  conjugate  diameter.  Barnes  maintains 
that,  although  an  unusually  compressible 
head  may  be  drawn  through  a  pelvis  con- 
tracted to  3  inches,  the  chance  of  the  child 
being  born  alive  under  such  circumstances 
must  necessarily  be  small,  and  that  from  3|  inches  to  the  normal  size 
must  be  taken  as  the  proper  limits  of  the  operation. 

FIG.  137. 


Showing  the  greater  breadth  of 
the  Bi-parietal  Diameter  of 
the  FoBtal  Cranium.  (After 
Simpson.) 


Showing  the  greater  space  for  the  Bi-parietal  Diameter  at  the  side  of  the  Pelvis  in  certain 
cases  of  Deformity.     (After  Simpson.) 

That  delivery  is  often  possible  by  turning,  after  the  forceps  and 
the  natural  powers  have  failed,  and  when  no  other  resource  is  left 
but  the  destruction  of  the  child,  must,  I  think,  be  admitted  by  all ; 


DEFORMITIES    OF    THE    PELVIS.  385 

for  the  records  of  obstetrics  are  full  of  such  cases.  To  take  one  ex- 
ample only,  Dr.  Braxton  Hicks1  records  four  cases  in  which  the  for- 
ceps were  tried  unsuccessfully,  in  all  of  which  version  was  used, 
three  of  the  children  being  born  alive.  Here  are  the  lives  of  three 
children  rescued  from  destruction,  within  a  short  period,  in  the 
practice  of  one  man ;  and  a  fact  like  this  would,  of  itself,  be  ample 
justification  of  the  attempt  to  deliver  by  turning,  when  the  child  was 
known  to  be  alive,  and  other  means  had  failed.  The  possibility  that 
craniotomy  may  still  be  required  is  no  argument  against  the  opera- 
tion ;  for,  although  perforation  of  the  after-corning  head  is  certainly 
not  so  easy  as  perforation  of  a  presenting  head,  it  is  not  so  much 
more  difficult  as  to  justify  the  neglect  of  an  expedient  by  which  it 
may  possibly  be  altogether  avoided. 

Comparative  Estimate  of  the  T-wo  Operations. — The  original  choice 
of  turning  is  a  more  difficult  question  to  decide.  My  own  impression 
is  that  the  use  of  the  forceps  will  generally  be  found  to  be  preferable. 
An  exception  should,  I  think,  be  made  for  those  cases  in  which  the 
head  refuses  to  enter  the  brim,  and  cannot  be  sufficiently  steadied 
by  external  pressure  to  admit  of  an  easy  application  of  the  instru- 
ment. Under  these  circumstances  increasing  experience  leads  me  to 
prefer  turning  as  decidedly  the  simpler  and  safer  operation,  and  the 
passage  of  the  head  through  the  contracted  brim  can  be  very  mate- 
rially facilitated  by  strong  pressure  from  above,  as  has  been  so  well 
pointed  out  by  Goodell.2 

An  argument  used  by  Martin,  of  Berlin,3  in  reference  to  the  two 
operations,  should  not  be  lost  sight  of,  as  it  seems  to  be  a  valid  reason 
for  giving  a  preference  to  the  forceps.  He  points  out  that  moulding 
may  safely  be  applied  for  hours  to  the  vertex ;  but  that  when  pres- 
sure is  applied  to  the  important  structures  about  the  base  of  the 
brain,  as  after  turning,  moulding  cannot  be  continued  beyond  five 
minutes  without  proving  fatal.  This,  however,  is  no  reason  why 
turning  should  not  be  used  after  the  forceps  and  the  natural  efforts 
have  proved  ineffectual. 

Craniotomy  or  the  Csesarean  Section  is  required. — When  the  con- 
traction is  below  3  inches  in  the  conjugate,  or  when  the  forceps  and 
turning  have  failed,  no  resource  is  left  but  the  destruction  of  the 
foetus,  or  the  Caesarean  section. 

The  induction  of  premature  labor  as  a  means  of  avoiding  the  risks 
of  delivery  at  term,  and  of  possibly  saving  the  life  of  the  child,  must 
now  be  studied.  The  established  rule,  in  this  country,  is,  that  in  all 
cases  of  pelvic  deformity,  the  existence  of  which  has  been  ascertained 
either  by  the  experience  of  former  labors,  or  by  accurate  examina- 
tion of  the  pelvis,  labor  should  be  induced  previous  to  the  full  period, 
so  that  the  smaller  and  more  compressible  head  of  the  premature 
foetus  may  pass,  where  that  of  the  foetus  at  term  could  not.  The 
gain  is  a  double  one,  partly  the  lessened  risk  to  the  mother,  and 
partly  the  chance  of  saving  the  child's  life. 

1  Guy's  Hosp.  Rep.  1870.  !  Amer.  Journ.  of  Obst.,  vol.  viii. 

3  Mo'n.  f.  Gebert.  1867. 


386  LABOR. 

The  practice  is  so  thoroughly  recognized  as  a  conservative  and 
judicious  one,  that  it  might  be  deemed  unnecessary  to  argue  in  its 
favor,  were  it  not  that  some  most  eminent  authorities  have  of  late 
years  tried  to  show,  that  it  is  better  and  safer  to  the  mother  to  leave 
the  labor  to  corne  on  at  term ;  and  that  the  risk  to  the  child  is  so 
great  in  artificially  induced  labor  as  to  lead  to  the  conclusion  that 
the  operation  should  be  altogether  abandoned,  except,  perhaps,  in 
the  extreme  distortion  in  which  the  Csesarean  section  might  other- 
wise be  necessary.  Prominent  amongst  those  who  hold  these  views 
are  Spiegelberg  and  Litzrnann,  and  they  have  been  supported,  in  a 
modified  form,  by  Matthews  Duncan.  Spiegelberg1  tries  to  show, 
by  a  collection  of  cases  from  various  sources,  that  the  results  of  in- 
duced labor  in  contracted  pelvis  are  much  more  unfavorable  than 
when  the  cases  are  left  to  nature ;  that  in  the  latter  the  mortality  of 
the  mothers  is  6.6  per  cent.,  and  of  the  children  28.7  per  cent.,  whereas 
in  the  former  the  maternal  deaths  are  15  per  cent.,  and  the  infantile 
66.9  per  cent.  Litzmann2  arrives  at  not  very  dissimilar  results, 
namely,  6.9  per  cent,  of  the  mothers  and  20.3  per  cent,  of  the  children 
in  contracted  pelvis  at  term,  and  14.7  per  cent,  of  the  mothers  and 
55.8  per  cent,  of  the  children,  in  artificially  induced  premature  labor. 

If  these  statistics  were  reliable,  inasmuch  as  they  show  a  very 
decided  risk  to  the  mother,  there  might  be  great  force  in  the  argu- 
ment that  it  would  be  better  to  leave  the  cases  to  run  the  chance  of 
delivery  at  term.  It  is,  however,  very  questionable  whether  they 
can  be  taken,  in  themselves,  as  being  sufficient  to  settle  the  question. 
The  fallacy  of  determining  such  points  by  a  mass  of  heterogeneous 
cases,  collected  together  without  a  careful  sifting  of  their  histories, 
has  over  and  over  again  been  pointed  out ;  and  it  would  be  easy 
enough  to  meet  them  by  an  equal  catalogue  of  cases  in  which  the 
maternal  mortality  is  almost  nil.  The  results  of  the  practice  of 
many  authorities  are  given  in  Churchill's  work,  where  we  find,  for 
example,  that  out  of  46  cases  of  Merriman's,  not  one  proved  fatal. 
The  same  fortunate  result  happened  in  62  cases  of  Kambotham's. 
His  conclusion  is,  that  "  there  is  undoubtedly  some  risk  incurred  by 
the  mother,  but  not  more  than  by  accidental  premature  labor,"  and 
this  conclusion,  as  regards  the  mother,  is  that  which  has  long  ago 
been  arrived  at  by  the  majority  of  British  obstetricians,  who  un- 
doubtedly have  more  experience  of  the  operation  than  those  of  any 
other  nation.  With  regard  to  the  child,  even  if  the  German  statis- 
tics be  taken  as  reliable,  they  would  hardly  be  accepted  as  contra- 
indicating  the  operation,  inasmuch  as  it  is  intended  to  save  the  mother 
from  the  dangers  of  the  more  serious  labor  at  term,  and,  in  many 
cases,  to  give  at  least  a  chance  to  the  child,  whose  life  would  other- 
wise be  certainly  sacrificed.  The  result,  moreover,  must  depend  to  a 
great  extent  on  the  method  of  operation  adopted,  for  many  of  the 
plans  of  inducing  labor  recommended  are  certainly,  in  themselves, 
not  devoid  of  danger  both  to  the  mother  and  the  child.  It  may,  I 

1  Arch.  f.  Gyn.  b.  i.  s.  1.  2  Ib.  b.  ii.  s.  169. 


DEFORMITIES    OF    THE    PELVIS. 


387 


think,  be  admitted,  as  Duncan  contends,1  that  the  operation  has 
been  more  often  performed  than  is  absolutely  necessary,  and  that  the 
higher  degrees  of  pelvic  contraction  are  much  more  uncommon  than 
has  been  supposed  to  be  the  case.  That  is  a  very  valid  reason  for 
insisting  on  a  careful  and  accurate  diagnosis,  but  not  for  rejecting  an 
operation  which  has  so  long  been  an  established  and  favorite  re- 
source. 

Determination  of  Period  for  Inducing  Labor. — When  the  induc- 
tion of  labor  has  been  determined  on,  the  precise  period  at  which  it 
should  be  resorted  to  becomes  a  question  for  anxious  consideration, 
for  the  longer  it  is  delayed  the  greater,  of  course,  are  the  dangers  for 
the  child.  Many  tables  have  been  constructed  to  guide  us  on  this 
point,  which  are  not,  on  the  whole,  of  so  much  service  as  they  might 
appear  to  be,  on  account  of  the  difficulty  of  determining  with  minute 
accuracy  the  amount  of  contraction.  The  following,  however,  which 
is  drawn  up  by  Kiwisch,  may  serve  for  a  guide  in  settling  this  ques- 
tion : — 


Inches. 
When  the  sacro-pubic  diameter  is  2  and 

2  8   "     9 

2  10   "  11 

3  — 
3  1 

3  2   "     3 

3  4   "     5 

.3  5   "     6 


Lines. 
6  or    7  induce  labor  at  30th  week. 


31st 
32d 
33d 
33d 
34th 
35th 
36th 


In  cases  of  moderate  deformity,  when  labor  pains  have  been  in- 
duced, the  further  progress  of  the  case  may  be  left  to  nature ;  but, 
in  the  more  marked  cases,  as  in  those  below  3  inches,  it  will  often 
be  found  necessary  to  assist  delivery  by  turning  or  by  the  forceps, 
the  former  being  here  specially  useful,  on  account  of  the  extreme 
pliability  of  the  head,  and  the  facility  with  which  it  may  be  drawn 
through  the  contracted  brim.  By  thus  combining  the  two  operations 
it  may  be  quite  possible  to  secure  the  birth  of  a  living  child  even  in 
pelves  very  considerably  deformed. 

Production  of  Abortion  in  extreme  Deformity. — When  the  contraction 
is  so  great  as  to  necessitate  the  induction  of  the  labor  before  the  sixth 
month,  or,  in  other  words,  before  the  child  has  reached  a  viable  age, 
it  would  be  preferable  to  resort  to  a  very  early  production  of  abor- 
tion. The  operation  is  then  indicated,  not  for  the  sake  of  the  child, 
but  to  save  the  mother  from  the  deadly  risk  to  which  she  would 
otherwise  be  subjected.  As,  in  these  cases,  the  mother  alone  is  con- 
cerned, the  operation  should  be  performed  as  soon  as  we  have  posi- 
tively determined  the  existence  of  pregnancy.  No  object  can  be 
gained  by  waiting  until  the  development  of  the  child  is  advanced  to 
any  extent,  and  the  less  the  foetus  is  developed,  the  less  will  be  the 
pain  and  risks  the  mother  has  to  undergo.  There  is  no  amount  of 
deformity,  however  great,  in  which  we  could  not  succeed  in  bringing 


1  Edin.  Med.  Journ.,  July,  1873,  p.  339. 


388  LABOR. 

on  miscarriage  by  some  of  the  numerous  means  at  our  disposal ;  and, 
in  spite  of  Dr.  Bedford's  objections,  who  maintains  that  the  obstetri- 
cian is  not  justified  in  sacrificing  the  life  of  a  human  being  more  than 
once,  when  the  mother  knows  that  she  cannot  give  birth  to  a  viable 
child,  there  are  few  practitioners  who  would  not  deem  it  their  duty 
to  spare  the  mother  the  terrible  dangers  of  the  Cossarean  section. 


CHAPTER  XIII. 

HEMORRHAGE  BEFORE  DELIVERY:    PLACENTA  PR^EVIA. 

THE  hemorrhages  which  are  the  result  of  an  abnormal  situation 
of  the  placenta,  partially  or  entirely,  over  the  internal  os  uteri,  have 
formed  a  most  fruitful  theme  for  discussion.  The  causes  producing 
the  abnormal  placental  site,  the  sources  of  the  blood,  and  the  causes 
of  its  escape,  the  means  adopted  by  nature  for  its  arrest,  and  the 
proper  treatment,  have,  each  and  all  of  them,  been  the  subject  of 
endless  controversies,  which  are  not  yet  by  any  means  settled.  It 
must  be  admitted,  too,  that  the  extreme  importance  of  the  subject 
amply  justifies  the  attention  which  has  been  paid  to  it;  for  there  is 
no  obstetric  complication  more  apt  to  produce  sudden  and  alarming 
effects,  and  none  requiring  more  prompt  and  scientific  treatment. 

By  placenta  prievia  we  mean  the  insertion  of  the  placenta  at  the 
lower  segment  of  the  uterine  cavity,  so  that  part  of  it  is  situated, 
wholly  or  partially,  over  the  internal  os  uteri.  In  the  former  case 
there  is  complete  or  central  placental  presentation,  in  the  latter  an 
incomplete  or  marginal  presentation. 

Causes. — The  causes  of  this  abnormal  placental  site  are  not  fully 
understood.  It  was  supposed  by  Tyler  Smith  to  depend  on  the  ovule 
not  having  been  impregnated  until  it  had  reached  the  lower  part  of 
the  uterine  cavity.  Cazeau  suggests  that  the  uterine  mucous  mem- 
brane is  less  swollen  and  turgid  than  when  impregnation  occurs  at 
the  more  ordinary  place,  and  that,  therefore,  it  offers  less  obstruction 
to  the  descent  of  the  ovule  to  the  lower  part  of  the  uterine  cavity. 
An  abnormal  size,  or  unusual  shape,  of  the  uterine  cavity  may  also 
favor  the  descent  of  the  impregnated  ovule;  the  former  probably 
explains  the  fact,  that  placenta  prsevia  more  generally  occur  in  women 
who  have  borne  several  children.  These  are  merely  interesting  specu- 
lations having  no  practical  value,  the  fact  being  undoubted  that,  in 
a  not  inconsiderable  number  of  cases — estimated  by  Johnson  and 
Sinclair  as  1  out  of  573 — the  placenta  is  grafted  partially  or  entirely 
over  the  uterine  orifice. 

History. — Placenta  praevia  was  not  unknown  to  the  older  writers, 
who  believed  that  the  placenta  had  originally  been  situated  at  the 


HEMORRHAGE    BEFORE    DELIVERY. 

fundus,  from  which  it  had  accidentally  fallen  to  the  lower  part  of 
the  uterus.  Portal,  Levret,  Roederer,  and  especially  our  own  country- 
man Rigby,  were  among  those  whose  observations  tended  to  improve 
the  state  of  obstetrical  knowledge  as  to  its  real  nature.  To  Rigby 
we  owe  the  term  "unavoidable  hemorrhage"  as  a  synonym  for  placenta 
prsevia,  and  as  distinguishing  hemorrhage  from  this  source  from  that 
resulting  from  separation  of  the  placenta  at  its  more  usual  position, 
termed  by  him,  in  centra-distinction,  " accidental  liemorrhaye.'1''  These 
names,  adopted  by  most  writers  on  the  subject,  are  obviously  mis- 
leading, as  they  assume  an  essential  distinction  in  the  etiology  of  the 
hemorrhage  in  the  two  classes  of  cases,  which  is  not  always  warranted 

It  is  of  the  utmost  importance  to  a  right  understanding  of  the 
nature  and  treatment  of  placenta  pros  via  that  we  should  fully  under- 
stand the  source  of  the  hemorrhage,  and  the  manner  of  its  produc- 
tion; but  we  shall  be  able  to  discuss  this  subject  better  after  a 
description  of  the  symptoms. 

Symptoms. — Although  the  placenta  must  occupy  its  unusual  site 
from  the  earliest  period  of  its  formation,  it  rarely  gives  rise  to  appre- 
ciable symptoms  before  the  last  three  months  of  utero-gestation.  It 
is  far  from  unlikely,  however,  that  such  an  abnormal  situation  of  the 
placenta  may  produce  abortion  in  the  earlier  months,  the  site  of  its 
attachment  passing  unobserved. 

Sudden  Flow  of  Blood. — The  earliest  symptom  which  causes  suspi- 
cion is  the  sudden  occurrence  of  hemorrhage,  without  any  appreciable 
cause.  The  amount  of  blood  lost  varies  considerably.  In  some  cases 
the  first  hemorrhage  is  comparatively  slight,  and  is  soon  spontaneously 
arrested ;  but,  if  the  case  be  left  to  itself,  the  flow  after  a  lapse  of 
time — it  may  be  a  few  days,  or  it  may  be  weeks — again  commences 
in  the  same  unexpected  way,  and  each  successive  hemorrhage  is  more 
profuse.  The  losses  show  themselves  at  different  periods.  They 
rarely  begin  before  the  end  of  the  sixth  month,  more  often  nearer 
the  full  period,  and  sometimes  not  until  labor  has  actually  com- 
menced. The  hemorrhage  very  often  coincides  with  what  would 
have  been  a  menstrual  period;  doubtless  on  account  of  the  physio- 
logical congestion  of  the  uterine  organs  then  present.  Should  the 
first  loss  not  show  itself  until  at  or  near  the  full  time,  it  may  be 
tremendous,  and  a  few  moments  may  suffice  to  place  the  patient's 
life  in  jeopardy.  Indeed  it  may  be  safely  accepted  as  an  axiom,  that 
once  hemorrhage  has  occurred,  the  patient  is  never  safe;  for  excessive 
losses  may  occur  at  any  moment  without  warning,  and  when  assist- 
ance is  not  at  hand.  It  often  happens  that  premature  labor  comes 
on  after  one  or  more  hemorrhages. 

In  any  case  of  placenta  praevia,  when  labor  has  commenced, 
whether  premature  or  at  the  full  time,  the  hemorrhage  may  become 
excessive,  and  with  each  pain  fresh  portions  of  placenta  may  be  de- 
tached, and  fresh  vessels  torn  and  left  open,  tinder  these  circum- 
stances the  blood  often  escapes  in  greater  quantity  with  each  suc- 
cessive pain,  and  diminishes  in  the  intervals.  This  has  long  been 
looked  upon  as  a  diagnostic  mark  by  which  we  can  distinguish  be- 
tween the  so-called  " unavoidable  "  and  ' 'accidental"  hemorrhage  ; 


390  LABOR. 

in  the  latter  the  flow  being  arrested  during  the  pains.  The  distinc- 
tion, however,  is  altogether  fallacious.  The  tendency  of  uterine 
contraction  in  placenta  prsevia,  as  in  all  other  forms  of  uterine 
hemorrhage,  is  to  constrict  the  vessels  from  which  the  blood  escapes, 
and  so  to  lessen  the  flow.  The  apparently  increased  flow  during  the 
pains  depends  on  the  pains  forcing  out  blood  which  has  already 
escaped  from  the  vessels.  In  one  way,  up  to  a  certain  point,  the 
pains  do  favor  hemorrhage,  by  detaching  fresh  portions  of  placenta; 
but  the  actual  loss  takes  place  chiefly  during  the  intervals,  and  not 
during  the  continuance  of  contraction. 

Results  of  Vaginal  Examination. — On  vaginal  examination,  if  the 
os  be  sufficiently  open  to  admit  the  finger,  which  it  generally  is  on 
account  of  the  relaxation  produced  by  the  loss  of  blood,  we  shall 
almost  always  be  able  to  feel  some  portion  of  presenting  placenta. 
If  it  be  a  central  implantation,  we  shall  find  the  upper  aperture  of 
the  cervix  entirely  covered  by  a  thick,  boggy  mass,  which  is  to  be 
distinguished  from  a  coagulum  by  its  consistence,  and  by  its  not 
breaking  down  under  the  pressure  of  the  finger.  Through  the  pla- 
cental  mass  we  may  feel  the  presenting  part  of  the  foetus ;  but  not 
as  distinctly  as  when  there  is  no  intervening  substance.  In  partial 
placental  presentations  the  bag  of  membranes,  and  above  it  the  head 
or  other  presentation,  will  be  found  to  occupy  a  part  of  the  circle  of 
the  os,  the  rest  being  covered  by  the  edge  of  the  placenta.  In  mar- 
ginal presentations  we  may  only  be  able  to  make  out  the  thickened 
edge  of  the  after-birth,  projecting  at  the  rim  of  the  os.  If  the  cer- 
vix be  high,  and  the  gestation  not  advanced  to  term,  these  points 
may  not  be  easy  to  make  out,  on  account  of  the  difficulty  of  reaching 
the  cervix ;  and,  as  accurate  diagnosis  is  of  the  utmost  importance, 
it  is  proper  to  introduce  two  fingers,  or  even  the  whole  hand,  so  as 
thoroughly  to  explore  the  condition  of  the  parts.  The  lower  portion 
of  the  uterine  ovoid  may  be  observed  to  be  more  than  usually  thick 
and  fleshy ;  and  Gendrin  has  pointed  out  that  ballottement  cannot  be 
made  out.  The  accuracy  of  our  diagnosis  may  be  confirmed,  in 
doubtful  cases,  by  finding  that  the  placental  bruit  is  heard  over  the 
lower  part  of  the  uterine  tumor. 

Dr.  Wallace1  has  suggested  that  vaginal  auscultation  may  be  ser- 
viceable in  diagnosis,  and  states  that,  by  means  of  a  curved  wooden 
stethoscope,  the  placental  bruit  may  be  heard  with  startling  distinct- 
ness. This  is,  however,  a  manoeuvre  that  can  hardly  be  generally 
carried  out  in  actual  practice. 

The  Source  of  Hemorrhage. — It  is  now  generally  admitted  by  au- 
thorities that  the  immediate  source  of  the  hemorrhage  is  the  lacerated 
utero- placental  vessels.  Only  a  few  years  ago  Sir  James  Simpson 
advocated,  with  his  usual  energy,  the  theory,  sustained  by  his  pre- 
decessor, Dr  Hamilton,  that  the  chief,  if  not  the  only,  source  of 
hemorrhage  was  the  detached  portion  of  the  placenta  itself.  He 
argued  that  the  blood  flowed  from  the  portion  of  the  placenta  which 
was  still  adherent  into  that  which  was  separated,  and  escaped  from 

1  E«lin.  Med.  Journ.,  Nov.  1872. 


HEMORRHAGE    BEFORE    DELIVERY.  391 

the  surface   of  the   latter ;    and   on    this    supposition    lie   based   his 
practiee  of  entirely  separating  the  placenta,  having  observed  that,  in 
many  cases  in  which  the  after-birth  had  been  expelled  before  the 
child,  the  hemorrhage  had  ceased.     The  fact  of  the  cessation  of  the 
hemorrhage,  when  this  occurs,  is  not  doubted;  but  Simpson's  expla- 
nation is  contested  by  most  modern  writers,  prominent  among  whom 
is  Barnes,  who  has  devoted  much  study  to  the  elucidation  of  the  sub- 
ject.    He  points  out  that  the  stoppage  of  the  hemorrhage  is  not  due 
to  the  separation  of  the  placenta,  but  to  the  preceding  or  accompany- 
ing contraction  of  the  uterus,  which  seals  up  the  bleeding  vessels, 
just  as  it  does  in  other  forms  of  hemorrhage.     The  site  of  the  loss 
was  actually  demonstrated  by  the  late  Dr.  Mackenzie  in  a  series  of 
experiments,  in  which  he  partial^  detached  the  placenta  in  pregnant 
bitches,  and  found  that  the  blood  flowed  from  the  walls  of  the  uterus, 
and  not  from  the  detached  surface  of  the  placenta.     The  arrange- 
ment of  the  large  venous  sinuses,  opening  as  they  do  on  the  uterine 
mucous  membrane,  favors  the  escape  of  blood  when  they  are  torn 
across ;  and  it  is  from  them,  possibly  to  some  extent  also  from  the 
uterine  arteries,  that  the  blood  comes,  just  as  in  post-partum  hemor- 
rhage, when  the  whole,  instead  of  a  part,  of  the  placenta!  side  is  bared. 
Causes  of  Hemorrhage. — Various  explanations  have  been  given  of 
the  causes  of  the  hemorrhage.     For  long  it  was  supposed  to  depend 
on  the  gradual  expansion  of  the  cervix  during  the  latter  months  of 
pregnancy,  which  separated  the  abnormally  placed  placenta.     It  has 
been  seen,  however,  that  this  shortening  of  the  cervix  is  apparent 
only,  and  that  the  cervical  canal  is  not  taken  up  into  the  uterine 
cavity  during  gestation,  or,  at  all  events,  only  during  the  last  week 
or  so.     This,  therefore,  cannot  be  admitted  as  an  explanation  of  pla- 
cental  separation.     Jacquemier  proposed  another  theory  which  has 
been  adopted  by  Cazeaux.     He  maintains  that  during  the  first  six 
months  of  utero-gestation  the  superior  portion  of  the  uterus  is  more 
especiallv  developed,  as  shown  by  the  pyriform  shape  of  the  fundus 
during  the  time;  and  that,  as  the  placenta  is  usually  attached  in  that 
situation,  and  then  attains  its  maximum  of  development,  its  relations 
to  its  attachments  are  undisturbed.    During  the  last  three  months  of 
pregnancy,  on  the  contrary,  the  lower  segment  of  the  uterus  develops 
more  than  the  upper,  while  the  placenta  remains  nearly  stationary 
in  size ;  the  inevitable  result  being  a  loss  of  proportion  between  the 
cervix  and  the  placenta,  and  the  detachment  of  the  latter.     There 
are  various  objections  which  can  be  brought  against  this  theory ; 
the  most  important  being  that  there  is  no  evidence  at  all  to  show 
that  the  lower  segment  of  the  uterus  does  expand  more  in  proportion 
than  the  upper  during  the  latter  months  of  pregnancy.     Barnes's 
theory  is  based  on  the  supposition  that  the  loss  of  relation  between 
the  uterus  and  placenta  is  caused  by  excess  of  growth  on  the  part 
of  the  placenta  itself  over  that  of  the  -cervix,  which  is  not  adapted 
for  its  attachment.     The  placenta,  on  this  hypothesis,  grows  away 
from  the  site  of  its  attachment,  and  hemorrhage  results.     It  will  be 
observed  that  neither  this  theory,  nor  that  propounded  by  Jacque- 
mier, are  readily  reconcilable  with  the  fact  that  hemorrhage  fre- 


392  LABOR. 

quently  does  not  begin  until  labor  has  commenced  at  term.  Inasmuch 
as  the  loss  of  relation  between  the  placenta  and  its  attachments, 
which  they  both  presuppose,  must  exist  in  every  case  of  placenta 
praevia,  hemorrhage  should  always  occur  during  some  part  of  the 
last  three  months  of  pregnancy.  Matthews  Duncan1  has  recently  in- 
vestigated the  whole  subject  at  length,  and  maintains  that  the  hemor- 
rhages are  accidental,  not  unavoidable,  being  due  to  precisely  similar 
•  causes  as  those  which  give  rise  to  the  occasional  hemorrhages  when 
the  placenta  is  normally  placed.  The  abnormal  situation  of  the  pla- 
centa, of  course,  renders  these  causes  more  apt  to  operate ;  but  in 
their  action  he  believes  them  to  be  precisely  similar  to  those  of  acci- 
dental hemorrhage,  properly  so  called.  Separation  of  the  placenta 
from  expansion  of  the  cervix,  he  believes  to  be  the  cause  of  hemor- 
rhage after  labor  has  begun,  and  then  it  may  strictly  be  called  una- 
voidable ;  but  hemorrhage  is  comparatively  seldom  so  produced 
during  the  continuance  of  pregnancy.  "  There  are,"  says  Duncan, 
"  four  ways  in  which  this  kind  of  hemorrhage  may  occur : — 

"  1.  By  the  rupture  of  a  utero-placental  vessel  at  or  about  the  in- 
ternal os  uteri. 

"2.  By  the  rupture  of  a  marginal  utero-placental  sinus  within  the 
area  of  spontaneous  premature  detachment,  when  the  placenta  is  in- 
serted not  centrally  or  covering  the  internal  os,  but  with  a  margin  at 
or  near  the  central  os. 

"  3.  By  partial  separation  of  the  placenta  from  accidental  causes, 
such  as  a  jerk  or  fall. 

"  4.  By  a  partial  separation  of  the  placenta,  the  consequence  of 
uterine  pains  producing  a  small  amount  of  dilatation  of  the  internal 
os.  Such  cases  may  be  otherwise  described  as  instances  of  miscar- 
riage commencing,  but  arrested  at  a  very  early  stage." 

I  see  no  reason  to  doubt  the  possibility  of  hemorrhage  being  due, 
in  many  cases,  to  the  first  three  causes,  and  in  its  production  it  would 
strictly  resemble  accidental  hemorrhage.  The  fourth  heading  refers 
the  hemorrhage  to  partial  separation,  in  consequence  of  commencing 
dilatation  of  the  cervix,  but  it  explains  the  dilatation  by  the  suppo- 
sition of  commencing  miscarriage.  This  latter  hypothesis  seems  to 
be  as  needless  as  those  which  presuppose  a  want  of  relation  between 
the  placenta  and  its  attachments.  We  know  that,  quite  independ- 
ently of  commencing  miscarriage,  uterine  contractions  are  constantly 
occurring  during  the  continuance  of  pregnancy.  There  is  reason  to 
suppose  that  these  contractions  do  not  affect  the  cervical,  as  well  as 
the  fundal  portions  of  the  uterus;  and  in  cases  in  which  the  placenta 
is  situated  partially  or  entirely  over  the  os,  one  or  more  stronger 
contractions  than  usual  may,  at  any  moment,  produce  laceration  of 
the  placental  attachments  in  that  neighborhood. 

Pathological  Changes  in  the  Placenta. — A  careful  examination  of 
the  placenta  may  show  pathological  changes  at  the  site  of  separation, 
such  as  have  been  described  by  Gendrin,  Simpson,  and  other  writers. 
They  probably  consist  of  thrombosis  in  the  placental  cotyledons,  and 

1  Edin.  Med.  Journ.,  Nov.  1873,  and  Brit.  Med.  Journ.,  Nov.  1873. 


HEMORRHAGE    BEFORE    DELIVERY.  303 

effused  blood-clots,  variously  altered  and  discolorized,  according  to 
the  lapse  of  time  since  separation  took  place.  Changes  occur  in  the 
portion  of  the  placenta  overlying  the  os  uteri,  whether  separation 
has  occurred  or  not.  There  may  be  atrophy  of  the  placental  struc- 
ture in  this  situation,  as  well  as  changes  of  form,  such  as  complete 
or  partial  separation  into  two  lobes,  the  junction  of  which  overlies 
the  os  uteri.1 

Natural  Termination  when  Placenta  presents. — The  history  of  de- 
livery, if  left  to  nature,  is  specially  worthy  of  study,  as  guiding  to 
proper  rules  of  treatment.  It  sometimes  happens,  when  the  pains 
are  very  strong  and  the  delivery  rapid,  that  labor  is  completed  with- 
out any  hemorrhage  of  consequence.  "Although,"  says  Cazeaux. 
"  hemorrhage  is  usually  considered  to  be  inevitable  under  such  cir- 
cumstances, yet  it  may  not  appear  even  during  the  labor ;  and  the 
dilatation  of  the  os  uteri  may  be  effected  without  the  loss  of  a  drop 
of  blood."  Again,  Simpson  conclusively  showed,  that  when  the 
placenta  was  expelled  before  the  birth  of  the  child,  all  hemorrhage 
ceased. 

Barnes's  theory  of  placenta  prsbvia,  which  has  been  pretty  gene- 
rally adopted,  explains  satisfactorily  both  these  classes  of  cases. 

He  describes  the  uterine  cavity  as  divisible  into  three  zones  or 
regions.  When  the  placenta  is  situated  in  the  upper  or  middle  of 
these  zones,  no  separation  or  hemorrhage  need  occur  during  labor. 
When,  however,  it  is  situated  partially  or  entirely  in  the  lower  or 
cervical  zone,  the  expansion  of -the  cervix  during  labor  must  produce 
more  or  less  separation,  and  consequent  loss  of  blood.  As  soon  as 
the  previous  portion  of  the  placenta  is  sufficiently  separated,  provided 
contraction  of  the  uterine  tissue  be  present  to  seal  up  the  mouths  of 
the  vessels,  hemorrhage  no  longer  takes  place.  The  placenta  may 
not  be  entirely  detached,  but  no  further  hemorrhage  occurs,  in  con- 
sequence of  the  remaining  portion  being  engrafted  on  the  uterus 
beyond  the  region  of  unsafe  attachment. 

In  the  former,  then,  of  these  classes  of  cases,  the  absence  of  hemor- 
rhage is  explained,  on  this  theory,  by  the  pains  being  sufficiently 
rapid  and  strong  to  complete  the  separation  of  the  placental  attach- 
ment from  the  lower  cervical  zone  before  flooding  had  taken  place ; 
in  the  latter,  it  ceases,  not  necessarily  because  the  entire  placenta  is 
expelled,  but  because  of  its  detachment  from  the  area  of  dangerous 
implantation. 

The  amount  of  cervical  expansion  required  for  this  purpose  varies 
in  different  cases.  Dr.  Duncan2  estimates  the  limit  of  the  spontaneous 
detaching  area  to  be  a  circle  of  4|  inches  diameter,  and  that,  after 
the  cervix  has  expanded  to  that  extent,  no  further  separation  or 
hemorrhage  takes  place.  To  admit  of  the  passage  of  a  full-sized 
head,  Barnes  estimates  that  expansion  to  about  a  circle  of  6  inches 
diameter  is  necessary  ;  on  the  other  hand  he  has  sometimes  observed 
"  that  the  hemorrhage  has  completely  stopped  when  the  os  uteri  had 
opened  to  the  size  of  the  rim  of  a  wineglass,  or  even  less." 

1  Sinelius,  Arch.  G6n.  de  M6d.,  vol.  ii.  1861.  2  Obst.  Trans.,  vol.  xv. 

26 


394  LABOR. 

It  will  be  seen  then  that  in  this,  as  in  every  other  form  of  peur- 
peral  hemorrhage,  the  tendency  of  uterine  contraction  is  to  check 
the  hemorrhage ;  and  that,  provided  the  pains  are  sufficiently  ener- 
getic, nature  may  be  capable  of  stopping  the  flooding  without  artifi- 
cial aid.  It  is  but  rarely,  however,  that  she  can  be  trusted  for  the 
purpose;  and  we  shall  presently  see  that  these  theoretical  views  have 
an  important  practical  bearing  on  the  subject  of  treatment. 

Prognosis. — The  prognosis  to  both  the  mother  and  child  is  cer- 
tainly grave  in  all  cases  of  placenta  praevia.  Read,  in  his  treatise 
on  placenta  praevia,  estimates  the  maternal  mortality,  from  the  statis- 
tics of  a  large  number  of  cases,  as  1  in  4|  cases,  and  Churchill  as  1 
in  3.  This  is  unquestionably  too  high  an  estimate,  and  based  on 
statistics  the  accuracy  of  which  cannot  be  relied  on.  The  mortality 
will,  of  course,  greatly  depend  on  the  treatment  adopted.  Doubtless, 
if  cases  were  left  to  nature,  the  result  would  be  quite  as  unfavorable 
as  Read  supposes.  But  if  properly  managed,  much  more  successful 
results  may  safely  be  anticipated.  Out  of  64  cases,  recorded  by 
Barnes,  the  deaths  were  6,  or  1  in  10|.  Under  any  circumstances 
the  risks  to  the  mother  are  very  great.  Churchill  estimates  that 
more  than  half  the  children  are  lost.  The  reasons  for  the  great 
danger  to  the  child  are  very  obvious,  subjected  as  it  is  to  the  risk  of 
asphyxia  from  the  loss  of  the  maternal  blood,  and  from  its  respira- 
tion being  carried  on  during  labor  by  a  placenta  which  is  only  par- 
tially attached ;  many  children  also  perish  from  prematurity,  or  from 
mal-presentation. 

Treatment. — Whenever,  in  the  latter  months  of  pregnancy,  a  sudden 
hemorrhage  occurs,  the  possibility  of  placenta  praevia  will  naturally 
suggest  itself;  and,  by  a  careful  vaginal  examination,  which  under 
such  circumstances  should  always  be  insisted  on,  the  existence  of 
this  complication  will  generally  be  readily  ascertained.  It  is  seldom 
that  the  os  is  not  sufficiently  dilated  to  enable  us  to  satisfy  ourselves 
whether  the  placenta  is  presenting. 

Is  it  justifiable  to  allow  the  Pregnancy  to  Continue? — The  first  ques- 
tion that  will  arise  is,  are  we  justified  in  temporizing,  using  means 
to  check  the  hemorrhage,  and  allowing  the  pregnancy  to  continue  ? 
This  is  the  course  which  has  generally  been  recommended  in  works 
on  midwifery.  We  are  told  to  place  the  patient  on  a  hard  mattress, 
not  to  heat  or  overburden  her  with  clothes,  to  keep  her  absolutely  at 
rest,  to  have  the  room  cool  and  well-aired,  to  apply  cold  cloths  -to  the 
vulva  and  lower  part  of  the  abdomen,  to  administer  cold  and  acidu- 
lated drinks  in  abundance,  and  to  prescribe  acetate  of  lead  and 
opium,  or  gallic  acid,  on  account  of  their  supposed  haemostatic  effect. 
Of  late  years  the  judiciousness  of  these  recommendations  has  been 
strongly  contested.  Not  long  ago  an  interesting  discussion  took 
place  at  the  Obstetrical  Society  of  London,1  on  a  paper  in  which  Dr. 
Greenhalgh  advised  the  immediate  induction  of  labor  in  all  cases  of 
placenta  praevia.  No  less  than  six  metropolitan  teachers  of  mid- 
wifery took  part  in  it;  and,  although  they  differed  in  details,  they 

1  Obst.  Trans.,  vol.  vi.  p.  188. 


HEMORRHAGE    BEFORE    DELIVERY.  395 

all  agreed  as  to  the  unadvisability  of  allowing  pregnancy  to  pro- 
gress when  the  existence  of  placenta  prsevia  had  been  distinctly 
ascertained.  The  reasons  for  this  course  are  obvious  and  unanswer- 
able. The  labor,  indeed,  very  often  comes  on  of  its  own  accord;  but 
should  it  not  do  so,  the  patient's  life  must  be  considered  to  be  always 
in  jeopardy  until  the  case  is  terminated,  for  no  one  can  be  sure  that 
most  dangerous,  or  even  fatal,  flooding  may  not  at  any  moment  come 
on ;  and  the  nearer  to  term  the  patient  is,  the  greater  the  risk  to 
which  she  is  subjected.  Nor  is  the  safety  of  the  child  likely  to  be 
increased  by  delay.  Provided  it  has  arrived  at  a  viable  age,  the 
chances  of  its  being  born  alive  may  be  said  to  be  greater  if  preg- 
nancy be  terminated  at  once,  than  if  repeated  floodings  occur.  I 
think,  therefore,  that  it  may  be  safely  laid  down  as  an  axiom,  that 
no  attempt  should  be  made  to  prevent  the  termination  of  pregnancy, 
but  that  our  treatment  should  rather  contemplate  its  conclusion  as 
soon  as  possible.  An  exception  may,  however,  be  made  to  this  rule 
when  the  hemorrhage  occurs  for  the  first  time  before  the  seventh 
month  of  utero-gestation.  The  chances  of  the  child  surviving  would 
then  be  very  small,  and  if  the  hemorrhage  be  not  alarming,  as  at 
that  early  period  is  likely  to  be  the  case,  the  measures  indicated 
above  may  be  employed,  in  the  hope  of  carrying  on  the  pregnancy 
until  there  is  a  prospect  of  the  patient  being  delivered  of  a  living 
child.  But  little  benefit  is  likely  to  accrue  from  astringent  drugs. 
Perfect  rest  in  bed  is  more  likely  to  be  beneficial  than  anything  else ; 
and  astringent  vaginal  pessaries,  of  matico  or  perchloride  of  iron, 
might  be  used  with  advantage  as  local  haemostatics. 

Various  Methods  of  Treatment. — When  the  period  of  pregnancy,  or 
the  urgency  of  the  case,  determines  us  to  forego  any  attempt  at  tem- 
porizing, there  are  various  plans  of  treatment  to  be  considered. 
These  are  chiefly — 1.  Puncture  of  the  membranes.  2.  Plugging  the 
vagina.  3.  Turning.  4.  Partial  or  complete  separation  of  the  placenta. 
It  will  be  well  to  Consider  in  detail  the  relative  advantages  of,  and 
indications  for,  each  of  these.  It  is  seldom,  however,  that  we  can 
trust  to  any  one  per  se ;  in  most  cases  two  or  more  are  required  to 
be  used  in  combination. 

1.  Puncture  of  the  membranes  is  recommended  by  Barnes  as  the 
first  measure  to  be  adopted  in  all  cases  of  placenta  praevia,  sufficient 
to  cause  anxiety.  "  It  is,"  he  says,  ''  the  most  generally  efficacious 
remedy,  and  it  can  always  be  applied."  The  primary  object  gained 
is  the  increase  of  uterine  contraction,  by  the  evacuation  of  the  liquor 
amnii.  Although  the  first  effect  of  this  may  be  to  increase  the  flow 
of  blood  by  further  separation  of  the  placenta,  the  flooding  can 
generally  be  commanded  by  plugging,  until  the  os  is  sufficiently 
dilated  to  permit  the  passage  of  the  child.  As  a  rule,  there  is  no 
great  difficulty  in  effecting  the  puncture,  especially  if  the  placental 
presentation  be  only  partial.  A  quill,  or  other  suitable  contrivance, 
guided  by  the  examining  finger,  is  passed  through  the  cervix,  and 
pushed  through  the  membranes.  In  complete  placenta  praevia  it  may 
not  be  so  easy  to  effect  the  evacuation  of  the  liquor  amnii ;  and,  al- 
though many  authorities  advise  the  penetration  of  the  substance  of 


396  LABOR. 

the  placenta  itself,  I  am  inclined  to  think  that  it  would  be  better  to 
abandon  the  attempt,  in  such  cases,  and  trust  to  other  methods  of 
treatment. 

The  objections  which  have  been  raised  to  puncture  of  the  mem- 
branes are  chiefly,  that  it  interferes  with  the  gradual  dilatation  of 
the  os,  and  renders  the  operation  of  turning  much  more  difficult. 
The  os  is  not,  however,  so  regularly  dilated  by  the  bag  of  membranes 
in  cases  of  placenta  pnievia,  as  it  is  in  ordinary  labors.  Moreover, 
the  cervical  tissues  are  generally  relaxed  by  the  hemorrhage,  and 
dilatation  is  easily  effected.  Should  we  desire  to  dilate  the  os,  pre- 
paratory to  turning,  we  can  readily  do  so  by  means  of  Barnes's  bags, 
which  act,  at  the  same  time,  as  an  efficient  plug.  The  objections, 
therefore,  are  not  so  weighty  as  they  might  have  been  before  these 
artificial  dilators  were  used.  I  am  inclined,  for  these  reasons,  to 
agree  with  the  recommendation  that  puncture  of  the  membranes 
-should  be  resorted  to  in  all  cases  of  placenta  praevia. 

2.  Plugging  of  the  vagina,  or,  still  better,  of  the  cavity  of  the  cer- 
vix itself,  is  specially  serviceable  in  cases  in  which  the  os  is  not  suffi- 
ciently dilated  to  admit  of  turning,  or  of  separation  of  the  placenta, 
and  in  which  the  hemorrhage  still  continues  after  the  evacuation  of 
the  liquor  amnii.     By  means  of  this  contrivance  the  escape  of  blood 
is  effectually  controlled. 

The  best  way  of  plugging  is  to  introduce  a  sponge  tent  of  sufficient 
size  into  the  cervical  canal,  and  to  keep  it  in  situ  by  a  vaginal  plug; 
the  best  material  for  the  latter,  and  the  method  of  introduction, 
are  described  under  the  head  of  abortion.  The  sponge  tent  not 
only  controls  the  hemorrhage  more  effectually  than  any  other  means, 
but  is,  at  the  same  time,  effecting  dilatation  of  the  cervix.  It  cannot 
be  left  in  many  hours  on  account  of  the  irritation  produced,  and  of 
the  fetor  from  accumulating  vaginal  discharges.  As  long  as  it  is  in 
position,  we  should  carefully  examine,  from  time  to  time,  to  see  that 
no  blood  is  oozing  past  it.  If  preferred,  a  Barnes's  bag  may  be  used 
for  the  same  purpose. 

While  the  plug  is  in  situ,  other  modes  of  exciting  uterine  action 
may  be  very  advantageously  employed,  such  as  a  firm,  abdominal 
bandage,  occasional  friction  over  the  uterus,  and  repeated  doses  of 
ergot.  The  last  is  specially  recommended  by  Dr.  Greenhalgh,  who 
uses,  at  the  same  time,  a  plug  formed  of  an  oblong  India-rubber  ball, 
inflated  with  air,  and  covered  with  spongio-piline. 

On  the  removal  of  the  plug  we  may  find  that  considerable  dila- 
tation has  taken  place,  perhaps  to  a  sufficient  extent  to  admit  ot 
labor  being  safely  concluded  by  the  natural  efforts.  In  that  case  we 
shall  find  that,  although  the  pains  continue,  no  fresh  hemorrhage 
occurs.  Should  it  do  so,  it  will  be  necessary  to  adopt  further 
measures. 

3.  Turning  has  long  been  considered  the  remedy  par  excellence  in 
placenta  praevia ;  and  it  is  of  unquestionable  value  in  suitable  cases. 
Much  harm,  however,  has  been  done  when  it  has  been  practised  be- 
fore the  os  was  sufficiently  dilated  to  admit  of  the  passage  of  the 
hand,  or  when  the  patient  w&s  so  exhausted  by  previous  hemorrhage 


HEMORRHAGE    BEFORE    DELIVERY.  397 

as  to  he  unable  to  bear  the  shock  of  the  operation.  The  records  of 
many  fatal  cases  in  the  practice  of  those  who  taught,  as  did  the  large 
majority  of  the  older  writers,  that  turning  at  all  risks  was  essential, 
conclusively  prove  this  assertion. 

It  is  most  likely  to  prove  serviceable  when,  either  at  first,  or  after 
the  use  of  the  tampon,  the  os  is  sufficiently  dilated  to  admit  the  hand, 
and  when  the  strength  of  the  patient  is  not  much  enfeebled.  If  she 
have  a  small,  feeble,  and  thready  pulse,  it  is  certainly  inapplicable, 
unless  all  other  methods  of  arresting  the  hemorrhage  have  failed. 
And,  even  then,  it  would  be  well  to  attempt  to  rally  the  patient  from 
her  exhausted  state  by  stimulants,  etc.,  before  the  operation  is  com- 
menced. 

Provided  the  placental  presentation  be  partial,  the  operation  can 
be  performed  without  difficulty  in  the  usual  way.  In  central  implan- 
tation the  passage  of  the  hand  may  give  rise  to  some  difficulty.  Dr. 
Eigby  recommends  that  it  should  be  pushed  through  the  substance 
of  the  placenta,  until  it  reaches  the  uterine  cavity.  It  is  hardly 
possible  to  conceive  how  this  could  be  done  without  completely 
detaching  the  placenta,  and  still  less  to  understand  how  the  fcetus 
could  be  dragged  through  the  aperture  thus  made.  It  will  be  far 
better  to  pass  the  hand  by  the  border  of  the  placenta,  separating  it 
as  we  do  so ;  and,  if  we  can  ascertain  to  which  side  of  the  cervix  it 
is  least  attached,  that  should  be  chosen  for  the  purpose.  In  all  cases 
in  which  it  is  possible,  turning  by  the  bi-polar  method  should  be 
preferred.  In  cases  of  placenta  prsevia  especially  it  offers  many  ad- 
vantages. The  operation  can  be  soon  performed;  complete  dilatation 
of  the  os  is  not  so  necessary;  and  it  involves  less  bruising  of  the 
cervix,  which  is  likely  to  be  specially  dangerous.  When  once  a  foot 
has  been  brought  within  the  os,  the  delivery  need  not  be  hurried. 
The  foot  forms  a  plug,  which  effectually  prevents  all  further  loss; 
and  we  may  then  safely  wait  until  we  can  excite  uterine  contraction, 
and  terminate  the  labor  with  safety.  Fortunately,  the  relaxation  of 
the  uterus,  which  is  so  often  present,  facilitates  this  manner  of  per- 
forming version,  and  it  can  generally  be  successfully  accomplished. 
Should  the  case  be  one  which  is  otherwise  suitable  for  turning,  and 
the  requisite  amount  of  dilatation  of  the  cervix  not  be  present,  the 
latter  can  generally  be  effected  in  the  space  of  an  hour  or  more 
(while  at  the  same  time  a  further  loss  of  blood  is  effectually  pre- 
vented) by  the  use  of  Barnes's  bags. 

4.  Separation  of  the  Placenta. — Entire  separation  of  the  placenta 
was  orignally  recommended  by  Simpson  in  his  well-known  paper  on 
the  subject.  The  reasons  which  induced  him  to  recommend  it  have 
already  been  stated.  It  is  a  mistake  to  suppose,  however,  as  is  so. 
often  done,  that  he  intended  to  recommend  it  in  all  cases  alike.  This 
supposition  he  always  was  careful  to  deny.  He  advised  it  especially : — 

1.  When  the  child  is  dead. 

2.  When  the  child  is  not  yet  viable. 

3.  When  the  hemorrhage  is  great  and  the  os  uteri  is  not  yet  suffi- 
ciently dilated  for  safe  turning.     This  was  the  state  in  11  out  of  89 
cases  (Lee). 


398  LABOR. 

4.  When  the  pelvic  passages  are  too  small  for   safe   and   easy 
turning. 

5.  When  the  mother  is  too  exhausted  to  bear  turning. 

6.  When  the  evacuation  of  the  liquor  amnii  fails. 

7.  When  the  uterus  is  too  firmly  contracted  for  turning.1 

These  are  very  much  the  cases  in  which  all  modern  accoucheurs 
would  exclude  the  operation  of  turning;  and  it  was  especially  when 
that  was  unsuitable  that  Simpson  advised  extraction  of  the  placenta. 
As  his  theory  of  the  source  of  hemorrhage  is  now  almost  universally 
disbelieved,  so  has  the  practice  based  on  it  fallen  into  disuse,  and  it 
need  not  be  discussed  at  length.  It  is  very  doubtful  whether  the 
complete  separation  and  extraction  of  the  placenta  was  a  feasible 
operation ;  unquestionably  it  can  be  by  no  means  so  easy  as  Simp- 
son's writings  would  lead  us  to  suppose.  The  introduction  of  the 
hand  far  enough  to  remove  the  placenta  in  an  exhausted  patient 
would  probably  cause  as  much  shock  as  the  operation  of  turning 
itself;  and  another  very  formidable  objection  to  the  procedure  is 
the  almost  certain  death  of  the  child,  if  any  time  elapse  between  the 
separation  of  the  placenta  and  the  completion  of  delivery.  The 
modification  of  this  method,  so  strongly  advocated  by  Barnes,  is 
certainly  much  easier  of  application,  and  would  appear  to  answer 
every  purpose  that  Simpson's  operation  effected.  It  is  impossible  to 
describe  it  better  than  in  Barnes's  own  words:2 

"  The  operation  is  this :  Pass  one  or  two  fingers  as  far  as  they  will 
go  through  the  os  uteri,  the  hand  being  passed  into  the  vagina  if 
necessary;  feeling  the  placenta,  insinuate  the  finger  between  it  and 
the  uterine  wall ;  sweep  the  finger  round  in  a  circle  so  as  to  separate 
the  placenta  as  far  as  the  finger  can  reach ;  if  you  feel  the  edge  of 
the  placenta,  where  the  membranes  begin,  tear  open  the  membranes 
carefully,  especially  if  these  have  not  been  previously  ruptured; 
ascertain,  if  you  can,  what  is  the  presentation  of  the  child  before 
withdrawing  your  hand.  Commonly,  some  amount  of  retraction  of 
the  cervix  takes  place  after  the  operation,  and  often  the  hemorrhage 
ceases" 

It  will  be  seen  from  what  has  been  said  that  no  one  rule  of  prac- 
tice can  be  definitely  laid  down  for  all  cases  of  placenta  prgevia.  Our 
treatment  in  each  individual  case  must  be  guided  by  the  particular 
conditions  that  are  present ;  and,  if  only  we  bear  in  mind  the  natural 
history  of  the  hemorrhage,  we  may  confidently  look  to  a  favorable 
termination. 

It  may  be  useful,  in  conclusion,  to  recapitulate  the  rules  which 
have  been  laid  down  for  treatment  in  the  form  of  a  series  of  pro- 
positions:— 

I.  Before  the  child  has  reached  a  viable  age,  temporize,  provided 
the  hemorrhage  be  not  excessive,  until  pregnancy  has  advanced  suffi- 
ciently to  afford  a  reasonable  hope  of  saving  the  child.  For  this 
purpose  the  chief  indication  is  absolute  rest  in  bed,  to  which  other 

1  Selected  Obst.  Works,  p.  68.  2  Obstet.  Operations,  2d  ed.,  p.  417. 


HEMORRHAGE    BEFORE    DELIVERY. 

accessory  means  of  preventing  hemorrhage,  such  as  cold,  astringent 
pessaries,  etc.,  may  be  added. 

II.  In  hemorrhage  occurrin«;  after  the  seventh  month  of  ntero- 

o  o 

gestation,  no  attempt  should  be  made  to  prolong  the  pregnancy. 

III.  In  all  cases  in  which  it  can  be  easily  effected,  the  membranes 
should  be  ruptured.     By  this  means  uterine  contractions  are  favored, 
and  the  bleeding  vessels  compressed. 

IV.  If  the  hemorrhage  be  stopped,  the  case  may  be  left  to  nature. 
If  flooding  continue,  and  the  os  be  not  sufficiently  dilated  to  admit 
of  the  labor  being  readily  terminated  by  turning,  the  os  and  the 
vagina  should  be  carefully  plugged,  while  uterine  contractions  are 
promoted  by  abdominal  bandages,  uterine  compression,  and  ergot. 
The  plug  must  not  be  left  in  beyond  a  few  hours. 

V.  If,  on  removal  of  the  plug,  the  os  be  sufficiently  expanded,  and 
the  general  condition  of  the  patient  be  good,  the  labor  may  be  ter- 
minated by  turning,  the  bi-polar  method  being  used  if  possible.     If 
the  os  be  not  open  enough,  it  may  be  advantageously  dilated  by  a 
Barnes's  bag,  which  also  acts  as  a  plug. 

VI.  Instead  of,  or  before  resorting  to,  turning,  the  placenta  may 
be  separated  around  the  site  of  its  attachment  to  the  cervix.     This 
practice  is  specially  to  be  preferred  when  the  patient  is  much  ex- 
hausted, and  in  a  condition  unfavorable  for  bearing  the  shock  of 
turning. 


CHAPTER  XIV. 

HEMORRHAGE  FROM  SEPARATION  OF  A  NORMALLY  SITUATED 

PLACENTA. 

THIS  is  the  form  of  hemorrhage  which  is  generally  described  in 
obstetric  works  as  "accidental"  in  centra-distinction  to  the  "unavoid- 
able" hemorrhage  of  placenta  prasvia.  In  discussing  the  latter,  we 
have  seen  that  the  term  "accidental"  is  one  that  is  apt  to  mislead, 
and  that  the  causation  of  the  hemorrhage  in  placenta  prgevia  is,  in 
some  cases  at  least,  closely  allied  to  that  of  the  variety  of  hemorrhage 
we  are  now  considering. 

When,  from  any  cause,  separation  of  a  normally  situated  placenta 
occurs  before  delivery,  more  or  less  blood  is  necessarily  effused  from 
the  ruptured  utero-placental  vessels,  and  the  subsequent  course  of 
the  case  may  be  twofold.  1.  The  blood,  or  at  least  some  part  of  it, 
may  find  its  way  between  the  membranes  and  the  decidua,  and 
escape  from  the  os  uteri.  This  constitutes  the  typical  "accidental" 
hemorrhage  of  authors.  2.  The  blood  may  fail  to  find  a  passage 
externally,  and  may  collect  internally,  giving  rise  to  very  serious 


400  LABOR. 

symptoms,  and  even  proving  fatal,  before  the  true  nature  of  the  case 
is  recognized.  Cases  of  this  kind  are  by  no  means  so  rare  as  the 
small  amount  of  attention  paid  to  them  by  authors  might  lead  us  to 
suppose;  and,  from  the  obscurity  of  the  symptoms  and  difficulty  of 
diagnosis,  they  merit  special  study.  Dr.  Goodell1  has  collected 
together  no  less  than  106  instances  in  which  this  complication 
occurred. 

Causes  and  Pathology. — The  causes  of  placental  separation  may  be 
very  various.  In  a  large  number  of  cases  it  has  followed  an  accident 
or  exertion  (such  as  slipping  down  stairs,  stretching,  lifting  heavy 
weights,  and  the  like),  which  has  probably  had  the  effect  of  lacerating 
some  of  the  placental  vattachments.  At  other  times  it  has  occurred 
without  such  appreciable  cause,  and  then  it  has  been  referred  to  some 
change  in  the  uterus,  such  as  a  more  than  usually  strong  contraction 
producing  separation,  or  some  accidental  determination  of  blood 
causing  a  slight  extravasation  between  the  placenta  and  the  uterine 
wall,  the  irritation  of  which  leads  to  contraction  and  further  detach- 
ment. Causes  such  as  these,  which  are  of  frequent  occurrence,  will 
not  produce  detachment  except  in  women  otherwise  predisposed  to 
it.  It  generally  is  met  with  in  women  who  have  borne  many  child- 
ren, more  especially  in  those  of  weakly  constitution  and  impaired 
health,  and  rarely  in  primiparae.  Certain  constitutional  states  proba- 
bly predispose  to  it,  such  as  albuminuria,  or  exaggerated  anaemia; 
and,  still  more  so,  degenerations  and  diseases  of  the  placenta  itself. 

This  form  of  hemorrhage  rarely  occurs  to  an  alarming  extent  until 
the  latter  months  of  pregnancy,  often  not  until  labor  has  commenced. 
The  great  size  of  the  placental  vessels  in  advanced  pregnancy  affords 
a  reasonable  explanation  of  this  fact. 

Symptoms  and  Diagnosis. — If,  after  separation  of  a  portion  of  the 
placenta,  the  blood  finds  its  way  between  the  membranes  and  the 
decidua,  its  escape  per  vaginam,  even  although  in  small  amount,  at 
once  attracts  attention,  and  reveals  the  nature  of  the  accident.  It 
is  otherwise  when  we  have  to  do  with  a  case  of  concealed  hemorrhage, 
the  diagnosis  of  which  is  often  a  matter  of  difficulty.  Then  the  blood 
probably  at  first  collects  between  the  uterus  and  the  placenta.  Some- 
times marginal  separation  does  not  occur,  and  large  blood-clots  are 
formed  in  this  situation,  and  retained  there.  More  often,  the  margin 
of  the  placenta  separates,  and  the  blood  collects  between  the  mem- 
branes and  the  uterine  wall,  either  towards  the  cervix,  where  the 
presenting  part  of  the  child  may  prevent  its  escape,  or  near  the 
fundus.  In  the  latter  case  especially,  the  coagula  are  apt  to  cause 
very  painful  stretching  and  distension  of  the  uterus.  The  blood 
may  also  find  its  way  into  the  amniotic  cavity,  but  more  frequently 
it  does  not  do  so;  probably,  as  Goodell  has  pointed  out,  because 
"should  the  os  uteri  be  closed,  the  membranes,  however  delicate, 
cannot,  other  things  being  equal,  rupture  any  sooner  from  the 
uterine  walls,  for  the  sum  of  the  resistance  of  the  inclosed  liquor 
amnii  being  equally  distributed  exactly  counterbalances  the  sum  of 

1  Amer.  Journ.  of  Obstet.,  vol.  ii. 


HEMORRHAGE    BEFORE    DELIVERY.  401 

the  pressure  exerted  by  the  effusion."  This  point  is  of  some  practical 
importance  because,  after  rupture  of  the  membranes,  the  liquor  amnii 
is  frequently  found  untinged  with  blood,  and  this  might  lead  us  to 
suppose  ourselves  mistaken  in  our  diagnosis,  if  this  fact  were  not 
borne  in  mind. 

Symptoms  of  Concealed  Accidental  IlemorrlMfje. — The  most  promi- 
nent symptoms  in  concealed  internal  hemorrhage  are  extreme  col- 
lapse and  exhaustion,  for  which  no  adequate  cause  can  be  assigned. 
These  differ  from  those  of  ordinary  syncope,  with  which  they  might 
be  confounded,  chiefly  in  their  persistence  and  severity,  and  in  the 
presence  of  the  symptoms  attending  severe  loss  of  blood,  such  as 
coldness  and  pallor  of  the  surface,  great  restlessness  and  anxiety, 
rapid  and  sighing  respiration,  yawning,  feeble,  quick,  and  compres- 
sible pulse.  When  there  is  severe  internal,  with  slight  external 
hemorrhage,  we  may  be  led  to  a  proper  diagnosis  by  observing  that 
the  constitutional  symptoms  are  much  more  severe  than  the  amount 
of  external  hemorrhage  would  account  for.  Uterine  pain  is  gene- 
rally present,  of  a  tearing  and  stretching  character,  sometimes  mode- 
rate in  amount,  more  often  severe,  and  occasionally  amounting  to 
intolerable  anguish.  It  is  often  localized,  and  it,  doubtless,  depends 
on  the  distension  of  the  uterus  by  the  retained  coagula.  If  the  dis- 
tension be  marked,  there  may  be  an  irregularity  in  the  form  of  the 
uterus  at  the  site  of  sanguineous  effusion ;  but  this  will  be  difficult 
to  make  out,  except  in  women  with  thin  and  unusually  lax  abdomi- 
nal parietes.  A  rapid  increase  in  the  size  of  the  uterus  has  been 
described  as  a  sign  by  Cazeaux  and  others.  It  is  not  very  likely 
that  this  will  be  appreciable  towards  the  end  of  utero-gestation,  as  a 
very  large  amount  of  effusion  would  be  necessary  to  produce  it.  At 
an  earlier  period  of  pregnancy,  at  or  about  the  fifth  month,  I  made  it 
out  very  distinctly  in  a  case  in  my  own  practice.  It  obviously  must 
have  occurred  to  an  enormous  extent  in  a  ease  related  by  Chevalier, 
in  which  post-mortem  Caesarean  section  was  performed  under  the  im- 
pression that  the  pregnancy  had  advanced  to  term,  but  only  a  three 
months'  foetus  was  found,  imbedded  in  coagula  which  distended  the 
uterus  to  the  size  of  a  nine  months'  gestation.1  Labor  pains  may  be 
entirely  absent.  If  present,  they  are  generally  feeble,  irregular,  and 
inefficient. 

Differential  Diagnosis. — The  only  condition,  besides  ordinary  syn- 
cope, likely  to  be  confounded  with  this  form  of  hemorrhage,  is  rup- 
ture of  the  uterus,  to  which  the  intense  pain  and  profound  collapse 
induce  considerable  resemblance.  The  latter  rarely  occurs  until  after 
labor  has  been  some  time  in  progress,  and  after  the  escape  of  the 
liquor  amnii ;  whereas  hemorrhage  usually  occurs  either  before  labor 
has  commenced,  or  at  an  early  stage.  The  recession  of  the  presenta- 
tion, and  the  escape  of  the  foetus  into  the  abdominal  cavity,  in  cases 
of  rupture,  will  further  aid  in  establishing  the  diagnosis. 

Prognosis. — The  prognosis,  when  blood  escapes  externally,  is,  on 
the  whole,  not  unfavorable.  The  nature  of  the  case  is  apparent,  and 

1  Journ.  do  Med.  Clin.  et  Pharmac..  vol.  xxi.  p.  363. 

col_Lliiu:  nii 

I-  K  \  S  I  C  I  L  U  £    c,    fc  U 


402  LABOR. 

remedial  measures  are  generally  adopted  sufficiently  early  to  prevent 
serious  mischief.  It  is  different  with  the  concealed  form,  in  which 
the  mortality  is  very  great.  Out  of  Goodell's  106  cases,  no  less  than 
54  mothers  died.  This  excessive  death-rate  is,  no  doubt,  partly  due  to 
the  fact  that  extreme  prostration  so  often  occurs  before  the  existence 
of  hemorrhage  is  suspected,  and  partly  to  the  accident  generally  hap- 
pening in  women  of  weakly  and  diseased  constitution.  The  prog- 
nosis to  the  child  is  still  more  grave.  Out  of  107  children,  only  6 
were  born  alive.  The  almost  certain  death  of  the  child  may  be  ex- 
plained by  the  fact  that,  when  blood  collects  between  the  uterus  and 
the  placenta,  the  foetal  portion  of  the  latter  is  probably  lacerated, 
and  the  child  then  also  dies  from  hemorrhage. 

Treatment. — In  this,  as  in  all  other  forms  of  puerperal  hemorrhage, 
the  great  hemostatic  is  uterine  contraction,  and  that  we  must  try  to 
encourage  by  all  possible  means.  The  first  thing  to  be  done,  whether 
the  hemorrhage  be  apparent  or  concealed,  is  to  rupture  the  mem- 
branes. If  the  loss  of  blood  be  only  slight,  this  may  suffice  to  con- 
trol it,  and  the  case  may  then  be  left  to  nature.  A  firm  abdominal 
binder  should,  however,  be  applied  to  prevent  any  risk  of  blood  col- 
lecting internally,  as  there  is  nothing  to  prevent  its  filling  the  uterine 
cavity  after  the  membranes  are  ruptured.  Contraction  may  be 
further  advantageously  solicited  by  uterine  compression,  and  by  the 
administration  of  full  doses  of  ergot.  If  hemorrhage  continue,  or  if 
we  have  any  reason  to  suspect  concealed  hemorrhage,  the  sooner  the 
uterus  is  emptied  the  better.  If  the  os  be  sufficiently  dilated,  the 
best  practice  will  be  to  turn  without  further  delay,  using  the  bi-polar 
method  if  possible.  If  the  os  be  not  open  enough,  a  Barnes's  bag 
should  be  introduced,  while  firm  pressure  is  kept  up  to  prevent 
uterine  accumulation.  Should  the  collapsed  condition  of  the  patient 
be  very  marked,  the  mere  shock  of  the  operation  might  turn  the 
scale  against  her.  Under  such  circumstances  it  may  be  better  prac- 
tice to  delay  further  procedure  until,  by  the  administration  of  stimu- 
lants, warmth,  etc.,  we  have  succeeded  in  producing  some  amount  of 
reaction,  keeping  up,  in  the  meanwhile,  firm  pressure  on  the  uterus. 
Should  the  head  be  low  down  in  the  pelvis,  it  may  be  easier  to  com- 
plete labor  by  means  of  the  forceps. 


CHAPTER  XV. 

HEMORRHAGE  AFTER  DELIVERY. 


HEMORRHAGE  during,  or  shortly  after,  the  third  stage  of  labor  is 
one  of  the  most  trying  and  dangerous  accidents  connected  with  partu- 
rition. Its  sudden  and  unexpected  occurrence  just  after  the  labor 
appears  to  be  happily  terminated,  and  its  alarming  effect  on  the 


HEMORRHAGE    AFTER    DELIVERY.  403 

patient,  who  is  often  placed  in  the  utmost  danger  in  a  few  moments, 
tax  the  presence  of  mind  and  the  resources  of  the  practitioner  to  the 
utmost,  and  render  it  an  imperative  duty  on  every  one  who  practises 
midwifery  to  make  himself  thoroughly  acquainted  with  its  causes, 
and  preventive  and  curative  treatment.  There  is  no  emergency  in 
obstetrics  which  leaves  less  time  for  reflection  and  consultation,  and 
the  life  of  the  patient  will  often  depend  on  the  prompt  and  imme- 
diate action  of  the  medical  attendant, 

Frequency  of  Post-partum  Hemorrhage. — Post-partum  hemorrhage 
is  one  of  the  most  frequent  complications  of  delivery.  I  do  not 
know  of  any  statistics  which  enable  us  to  judge  with  accuracy  of  its 
frequency,  but  I  believe  it  to  be  an  unquestionable  fact  that,  espe- 
cially in  the  upper  ranks  of  society,  it  is  very  common  indeed.  This 
is  probably  due  to  the  effects  of  civilization,  and  to  the  mode  of  life 
of  patients  of  that  class,  whose  whole  surroundings  tend  to  produce 
a  lax  habit  of  body  which  favors  uterine  inertia,  the  principal  cause 
of  post-partum  hemorrhage. 

Generally  a  Preventable  Accident. — Fortunately,  it  is,  to  a  great 
extent,  a  preventable  accident.  I  believe  this  fact  canno  t  be  too 
strongly  impressed  on  the  practitioner.  If  the  third  stage  of  labor 
be  properly  conducted,  if  every  case  be  treated,  as  every  case  ought 
to  .be,  as  if  hemorrhage  were  impending,  it  would  be  much  more  in- 
frequent than  it  is.  It  is  a  curious  fact  that  post-partum  hemorrhage 
is  much  more  common  in  the  practice  of  some  medical  men  than  in 
that  of  others ;  the  reason  being,  that  those  who  meet  with  it  often 
are  careless  in  their  management  of  their  patients  immediately  after 
the  birth  of  the  child.  That  is  just  the  time  when  the  assistance  of 
a  properly  qualified  practitioner  is  of  value,  much  more  so  than 
before  the  second  stage  of  labor  is  concluded ;  hence  when  I  hear 
that  a  medical  man  is  constantly  meeting  with  severe  post-partum 
hemorrhage,  I  hold  myself  justified  ipso  facto  in  inferring  that  he 
does  not  know,  or  does  not  practise,  the  proper  mode  of  managing 
the  third  stage  of  labor. 

Causes  and  Nature's  Method  of  Controlling  Hemorrhage  after  De- 
livery.— The  placenta,  as  we  have  seen,  is  separated  by  the  last  pains, 
and  the  blood,  which  in  greater  or  less  quantity  accompanies  the 
foetus,  probably  comes  from  the  utero-placental  vessels  which  are 
then  lacerated.  Almost  immediately  afterwards  the  uterus  contracts 
firmly,  and,  in  a  typical  labor,  assumes  the  hard  cricket-ball  form 
which  is  so  comforting  to  the  accoucheur  to  feel.  The  result  is  the 
compression  of  all  the  vascular  trunks  which  ramifv  in  its  walls,  botli 
arteries  and  veins,  and  thus  the  flow  of  blood  through  them  is  pre- 
vented. By  referring  to  what  has  been  said  as  to  the  anatomy  of  the 
muscular  fibres  of  the  gravid  uterus,  especially  at  the  placental  site 
(p.  52),  it  will  be  seen  how  admirably  they  are  adapted  for  this 
purpose.  The  arrangement  of  the  vessels  themselves  favors  the 
h^mostatic  action  of  uterine  contraction.  The  large  venous  sinuses 
are  placed  in  layers,  one  above  the  other,  in  the  thickness  of  the 
uterine  walls,  and  they  anastomose  freely.  When  the  superimposed 
layers  communicate  with  those  immediately  below  them,  the  June- 


404  LABOR. 

tion  is  by  a  falciform  or  semilunar  opening  in  the  floor  of  the  vessel 
nearest  the  external  surface  of  the  uterus.  Within  the  margins  of 
this  aperture  there  are  muscular  fibres,  the  contraction  of  which 
probably  tends  to  prevent  retrogression  of  blood  from  one  layer  of 
vessels  into  the  other.  The  venous  sinuses  themselves  are  of  a  flat- 
tened form,  and  they  are  intimately  attached  to  the  muscular  tissues. 
It  is  obvious,  then,  that  these  anatomical  arrangements  are  emi- 
nently adapted  to  facilitate  the  closure  of  the  vessels.  They  are, 
however,  large,  and  are  destitute  of  valves ;  and,  if  contraction  be 
absent,  or  if  it  be  partial  and  irregular,  it  is  equally  easy  to  under- 
stand why  blood  should  pour  forth  in  the  appalling  amount  which  is 
sometimes  observed. 

Importance  of  Tonic  Uterine  Contraction. — If  uterine  action  be  firm, 
regular,  and  continuous,  the  vessels  must  be  sealed  up,  and  hemor- 
rhage effectually  prevented.  This  fact  has  been  doubted  by  many 
authorities.  Gooch  was  the  first  to  describe  what  he  called  "  a  pecu- 
liar form  of  hemorrhage"  accompanying  a  contracted  womb,  and 
similar  observations  have  .been  made  by  other  writers,  such  as 
Velpeau,  Rigby,  and  Gendrin.  Simpson  says,  on  this  point,  that 
strong  uterine  contractions  "  are  not  probably  so  essential  a  part  in 
the  mechanism  of  the  prevention  of  hemorrhage  from  the  open  ori- 
fices of  the  uterine  veins  as  we  might  a  priori  suppose."1  With  re- 
gard to  Gooch's  cases,  it  has  been  pointed  out  that  his  own  description 
proves  that,  however  firmly  the  uterus  may  have  contracted  imme- 
diately after  the  expulsion  of  the  child,  it  must  have  subsequently 
relaxed,  for  he  passed  his  hand  into  it  to  remove  retained  clots,  a 
manoeuvre  which  he  could  not  have  practised  had  tonic  contraction 
been  present.  Barnes  suggests  that  in  some  of  these  cases  the 
hemorrhage  came  from  a  laceration  of  the  cervix.  Of  course,  blood 
may  readily  escape  from  a  mechanical  injury  of  this  kind,  although 
the  uterus  itself  be  in  a  satisfactory  state  of  contraction,  and  the 
possibility  of  this  occurrence  should  always  be  borne  in  mind. 

Although,  then,  we  may  admit  that  post-partum  hemorrhage  is 
incompatible  with  persistent  contraction  of  the  uterus,  it  by  no  means 
follows  that  the  converse  is  true.  On  the  contrary,  it  is  not  uncom- 
mon to  meet  with  cases  in  which  the  uterus  is  large  and  apparently 
quite  flaccid,  and  in  which  there  is  no  loss  of  blood.  Alternate  re- 
laxation and  contraction  of  the  uterus  after  delivery  are  also  of  con- 
stant occurrence,  and  yet  hemorrhage,  during  the  relaxation,  does 
not  take  place.  The  explanation  no  doubt  is  that,  immediately 
after  the  birth  of  the  child,  there  was  sufficient  contraction  to  pre- 
vent hemorrhage,  and  that,  during  its  continuance,  coagula  formed 
in  the  mouths  of  the  uterine  sinuses,  by  which  they  were  suffi- 
ciently occluded  to  prevent  any  loss  when  subsequent  relaxation 
occurred. 

In  all  probability  both  uterine  contraction  and  thrombosis  are  in 
operation  in  ordinary  cases ;  and  we  shall  presently  see  that  all  the 

1  Selected  Obstetric  Works,  p.  234. 


HEMORRHAGE    AFTER    DELIVERY.  405 

means  employed  in  the  treatment  of  post-partum  hemorrhage  act  by 
producing  one  or  other  of  thorn. 

Secondary  Causes  of  Hemorrhage. — Uterine  inertia  after  labor,  then, 
may  be  regarded  as  the  one  great  primary  cause  of  post-partum 
hemorrhage ;  but  there  are  various  secondary  causes  which  tend  to 
produce  it,  one  of  the  most  frequent  of  which  is  exhaustion  follow- 
ing a  protracted  labor.  The  uterus  gets  worn  out  by  its  efforts,  and 
when  the  foetus  is  expelled,  it  remains  in  a  relaxed  state,  and  hemor- 
rhage results.  Over-distension  of  the  uterus  acts  in  the  same  way. 
Hence  hemorrhage  is  very  frequently  met  with  when  there  has  been 
an  excessive  amount  of  liquor,  amnii,  or  in  multiple  pregnancies. 
One  of  the  worst  cases  I  ever  met  with  was  after  the  birth  of  triplets, 
the  uterus  having  been  of  an  enormous  size.  Rapid  emptying  of  the 
uterus,  during  which  there  has  not  been  sufficient  time  for  complete 
separation  of  the  placenta,  often  tends  to  the  same  result.  This  is 
the  reason  why  hemorrhage  so  frequently  follows  forceps  delivery, 
especially  if  the  operation  have  been  unduly  hurried ;  and  it  is  one 
of  the  chief  dangers  in  what  are  termed  "  precipitate  labors."  The 
general  condition  of  the  patient  may  also  strongly  predispose  to  it. 
Thus  it  is  more  often  met  with  in  women  who  have  borne  families, 
especiallv  if  they  be  weakly  in  constitution,  comparatively  seldom 
in  primiparge;  and  for  the  same  reason  that  after-pains  are  most 
common  in  the  former,  namely  that  the  uterus,  weakened  by  frequent 
child-bearing,  contracts  inefficiently.  The  experience  of  practitioners 
in  the  tropics  shows  that  European  women,  debilitated  by  the  relax- 
ing effects  of  warm  climates,  are  peculiarly  prone  to  it,  and  it  forms 
one  of  the  chief  dangers  of  childbirth  amongst  the  English  ladies  in 
India. 

Irregular  Uterine  Contraction. — Another  important  cause  of  post- 
partum  hemorrhage  is  partial  and  irregular  contraction  of  the  uterus. 
Part  of  the  muscular  tissue  is  firmly  contracted,  while  another  part 
is  relaxed,  and  the  latter  very  often  the  placental  site.  This  has 
been  especially  dwelt  on  by  Simpson.  He  says,  "  the  morbid  con- 
dition which  is  most  frequently  and  earliest  seen  in  connection  with 
post-partum  hemorrhage,  is  a  state  of  irregularity  and  want  of  equa- 
bility in  the  contractile  action  of  different  parts  of  the  uterus — and, 
it  may  be  in  different  planes  of  the  muscular  fibres — as  marked  by 
one  or  more  points  in  the  organ  feeling  hard  and  contracted,  at  the 
same  time  that  other  portions  of  the  parietes  are  soft  and  relaxed." 

Hour-glass  Contraction. — One  peculiar  variety,  which  has  been 
much  dwelt  on  by  writers,  and  is  a  prominent  bugbear  to  obstetri- 
cians, is  the  so-called  "  hour-glass  contraction.'1'1  This  in  reality  seems 
to  depend  on  spasmodic  contraction  of  the  internal  os  uteri,  by  means 
of  which  the  placenta  becomes  encysted  in  the  upper  portion  of  the 
uterus,  which  is  relaxed.  On  introducing  the  hand,  it  first  passes 
through  the  lax  cervical  canal,  until  it  comes  to  the  closed  internal 
os,  with  the  umbilical  cord  passing  through  it,  which  has  generally 
been  supposed  to  be  a  circular  contraction  of  a  portion  of  the  body 
of  the  uterus. 

[The  late  Prof.  Meigs  was  of  the  opinion  that  an  encysted  placenta 


406 


LABOR. 


was  always  an  adherent  one,  and  that  the  local  inertia  was  the  forced 
effect  of  the  adhesion,  preventing  mechanically  the  contraction  of  the 
uterus  over  the  utero-placental  space.  This  was  also  the  opinion  of 
Ramsbotham,  from  whose  work  the  following  plates  are  taken.  He 
had  never  seen  a  true  hour-glass  constriction,  such  as  the  right  hand 
drawing.  Miller  claims  to  have  met  with  the  condition  on  several  oc- 
casions.— ED.]  Encystment  of  the  placenta,  however,  although  more 
rarely,  unquestionably  takes  place  in  a  portion  only  of  the  body  of 
the  uterus  (Fig.  138).  Then  apparently  the  placental  site  remains 

FIG.  138. 


Irregular  Contraction  of  the  Uterus,  with  Eneystment  of  the  Placenta. 

more  or  less  paralyzed,  with  the  placenta  still  attached,  while  the 
remainder  of  the  body  of  the  uterus  contracts  firmly,  and  thus  encyst- 
ment  is  produced. 

Causes  of  Irregular  Contractions. — These  irregular  contractions  of 
the  uterus  are  by  no  means  so  common  as  our  older  authors  supposed. 
When  they  do  occur  I  believe  them  almost  invariably  to  depend  on 
defective  management  of  the  third  stage  of  labor.  "  The  most  fre- 
quent cause,"  says  Rigby,1  "is  from  over  anxiety  to  remove  the 
placenta ;  the  cord  is  frequently  pulled  at,  and  at  length  the  os  uteri 
is  excited  to  contract."  While  this  is  being  done,  no  attempts  are 
probably  being  made  to  excite  the  fundus  to  proper  action,  and, 
therefore,  the  hour-glass  contractipn  is  established.  Duncan  says  of 
this  condition :  "  Hour-glass  contraction  cannot  exist  unless  the  parts 
above  the  contraction  are  in  a  state  of  inertia ;  were  the  higher 
parts  of  the  uterus  even  in  moderate  action,  the  hour-glass  contrac- 
tion would  soon  be  overcome."2  If  placental  expression  were  always 
employed,  if  it  were  the  rule  to  effect  the  expulsion  of  the  placenta 
by  a  vis  d  tergo,  instead  of  extracting  by  a  vis  d  fronte,  I  feel  con- 
fident that  these  irregular  and  spasmodic  contractions — of  the  influ- 
ence of  which  in  producing  hemorrhage  there  can  be  no  question — 
would  rarely,  if  ever,  be  met  with.  Tt  is  to  be  observed  that  even 


Rigby' s  Midwifery,  p.  225. 


2  Researches  in  Obstetrics,  p.  889. 


HEMORRHAGE    AFTER    DELIVERY.  407 

in  these  cases,  it  is  not  because  the  uterus  is  in  a  state  of  partial  con- 
traction, but  because  it  is  in  a  state  of  partial  relaxation,  that  hemor- 
rhage ensues. 

Placental  Adhesions. — Adhesions  of  the  placenta  to  the  uterine 
parietes  may  cause  hemorrhage,  especially  if  they  be  partial,  and 
the  remainder  of  the  placenta;  be  detached.  The  frequency  of  these 
has  been  over-estimated.  Many  cases  believed  to  be  examples  of 
adherent  placenta  are,  in  reality,  only  cases  of  placentas  retained 
from  uterine  inertia.  The  experience  of  all  who  see  much  midwifery 
will  probably  corroborate  the  observation  of  Braun,  that  "abnormal 
adhesion  and  hour-glass  contraction  are  more  frequently  encountered 
in  the  experience  of  the  young  practitioner,  and  they  diminish  in 
frequency  in  direct  ratio  to  increasing  years."1  The  cause  of  adhe- 
sion is  often  obscure,  but  it  most  probably  results  from  a  morbid 
state  of  the  decidua,  which  is  produced  by  antecedent  disease  of  the 
uterine  mucous  membrane;  then  the  adhesion  is  apt  to  recur  in  sub- 
sequent pregnancies.  The  decidua  is  altered  and  thickened,  and 
patches  of  calcareous  and  fibrous  degeneration  may  be  often  found 
on  the  attached  surface  of  the  placenta.  Most  frequently  the  placenta 
is  only  partially  adherent ;  patches  of  it  remain  firmly  attached  to 
the  uterus,  while  the  rest  is  separated  ;  hence  the  uterine  walls  re- 
main relaxed,  and  hemorrhage  frequently  follows.  The  diagnosis 
and  management  of  these  very  troublesome  cases  will  be  found  de- 
scribed under  the  head  of  treatment  (p.  411). 

Constitutional  Predisposition  to  Flooding. — Finally  I  think  it  must 
be  admitted  that  there  are  some  women  who  really  merit  the  appel- 
lation of  "Flooders,"  which  has  been  applied  to  them,  and  who,  do 
what  we  may,  have  the  most  extraordinary  tendency  to  hemorrhage 
after  delivery.  I  do  not  think  that  these  cases,  however,  are  by  any 
means  so  common  as  some  have  supposed.2  I  have  attended  several 
patients  who  have  nearly  lost  their  lives  from  post-partum  hemor- 
rhage in  former  labors,  some  who  have  suffered  from  it  in  every  pre- 
ceding confinement,  and  I  have  only  met  with  two  cases  in  which 
the  assiduous  use  of  preventive  treatment  failed  to  avert  it.  In  these 
(one  of  which  I  have  elsewhere  published  in  detail3),  in  spite  of  all 
my  efforts,  I  could  not  succeed  in  keeping  up  uterine  contraction, 
and  the  patients  would  certainly  have  lost  their  lives  were  it  not  for 
the  means  which  modern  improvements  have  fortunately  placed  at 
our  disposal  for  producing  thrombosis  in  the  mouths  of  the  bleeding 
vessels.  The  nature  of  these  rare  cases  requires  further  investiga- 
tion ;  possibly  they  may,  to  some  extent,  be  the  subjects  of  the  so- 
called  hemorrhagic  diathesis. 

Signs  and  Symptoms. — The  loss  of  blood  may  commence  immedi- 
ately after  the  birth  of  the  child,  before  the  expulsion  of  the  placenta, 
or  not  until  some  time  afterwards,  when  the  contracted  uterus  has 
again  relaxed.  It  may  commence  gradually,  or  suddenly;  in  the 
latter  case,  it  may  begin  with  a  gush,  and  in  the  worst  form  the  bed- 

1  Braun's  Lectures,  1869.  [2  See  remarks  on  quinia,  p.  330. — ED.] 

3  Obst.  Journ.,  vol.  i. 


408  LABOK. 

clothes,  the  bed,  and  even  the  floor,  are  deluged  with  the  blood  which, 
it  is  no  exaggeration  to  say,  is  pouring  from  the  patient.  If  now  the 
hand  be  placed  on  the  abdomen,  we  shall  miss  the  hard  round  ball 
of  the  contracted  uterus,  which  will  be  found  soft  and  flabby,  or  we 
may  even  be  unable  to  make  out  its  contour  at  all.  If  the  hemor- 
rhage be  slight,  or  if  we  succeed  in  controlling  it  at  once,  no  serious 
consequences  follow  ;  but  if  it  be  excessive,  or  if  we  fail  to  check  it, 
the  gravest  results  ensue. 

Exhaustion  in  Extreme  Cases. — There  are  few  sights  more  appal- 
ling to  witness  than  one  of  the  worst  cases  of  post-partum  hemorrhage. 
The  pulse  becomes  rapidly  affected,  and  may  be  reduced  to  a  mere 
thread,  or  it  may  became  entirely  imperceptible.  Syncope  often 
comes  on,  not  in  itself  always  an  unfavorable  occurrence,  as  it  tends 
to  promote  thrombosis  in  the  venous  sinuses.  Or,  short  of  actual 
syncope,  there  may  be  a  feeling  of  intense  debility  and  faintness. 
Extreme  restlessness  soon  supervenes,  the  patient  throws  herself 
about  the  bed,  tossing  her  arms  wildly  above  her  head ;  respiration 
becomes  gasping  and  sighing,  the  "besoin  de  respirer"  is  acutely  felt, 
and  the  patient  cries  out  for  more  air ;  the  skin  becomes  deadly  cold, 
and  covered  with  profuse  perspiration ;  if  the  hemorrhage  continue 
unchecked,  we  next  may  have  complete  loss  of  vision,  jactitation, 
convulsions,  and  death. 

Formidable  as  such  symptoms  are,  it  is  satisfactory  to  know  that 
recovery  often  takes  place,  even  when  the  powers  of  life  seem  reduced 
to  the  lowest  ebb.  If  we  can  check  the  hemorrhage  while  there  is 
still  some  power  of  reaction  left,  however  slight,  we  may  not  unrea- 
sonably hope  for  eventual  recovery.  The  constitution,  however,  may 
have  received  a  severe  shock,  and  it  may  be  months,  or  even  years, 
before  the  patient  recovers  from  the  effects  of  only  a  few  minutes' 
hemorrhage.  A  death-like  pallor  frequently  follows  these  excessive 
losses,  and  the  patient  often  remains  blanched  and  exsanguine  for  a 
long  time. 

Preventive  Treatment. — The  preventive  treatment  of  post-partum 
hemorrhage  should  be  carefully  practised  in  every  case  of  labor, 
however  normal.  If  the  practitioner  make  a  habit  of  never  remov- 
ing his  hand  from  the  uterus  after  the  birth  of  the  child  until  the 
placenta  is  expelled,  and  of  keeping  up  continuous  uterine  contrac- 
tion for  at  least  half  an  hour  after  delivery  is  completed,  not  neces- 
sarily by  friction  on  the  fundus,  but  by  simply  grasping  the  contracted 
womb  with  the  palm  of  the  hand  and  preventing  its  undue  relaxation, 
cases  of  post-partum  flooding  will  seldom  be  met  with.  As  a  rule 
we  should,  I  think,  not  apply  the  binder  until  at  least  that  time  has 
elapsed.  The  binder  is  an  effective  means  of  keeping  up,  but  not  of 
producing,  contraction,  and  it  should  never  be  trusted  to  for  the  latter 
purpose.  If  it  be  put  on  too  soon,  the  uterus  may  relax  under  it, 
and  become  filled  with  clots  without  the  practitioner  knowing  any- 
thing about  it;  whereas  this  cannot  possibly  take  place  as  long  as 
the  uterine  globe  is  held  in  the  hollow  of  the  hand.  I  have  seen 
more  than  one  serious  case  of  concealed  hemorrhage  result  from  the 
too  common  habit  of  putting  on  the  binder  immediately  after  the 


HEMORRHAGE    AFTER    DELIVERY.  409 

removal  of  tlio  placenta.  I  believe  also,  as  I  have  formerly  said, 
that  it  is  thoroughly  good  practice  to  administer  a  full  dose  of  the 
liquid  extract  of  ergot  in  all  eases  after  the  placenta  has  been  ex- 
pelled, to  insure  persistent  contraction,  and  to  lessen  the  chance  of 
blood-clots  being  retained  in  utero. 

These  are  the  precautions  which  should  be  used  in  all  cases  alike; 
but  when  we  have  reason  to  fear  the  occurrence  of  hemorrhage,  from 
the  history  of  previous  labors  or  other  cause,  special  care  should 
be  taken.  The  ergot  should  be  given,  and  preferably  in  the  form  of 
the  subcutaneous  injection  of  ergotine,  before  the  birth  of  the  child, 
when  the  presentation  is  so  far  advanced  that  we  estimate  that  labor 
will  be  concluded  in  from  ten  to  twenty  minutes,  as  we  can  hardly 
expect  the  drug  to  produce  any  effect  in  less  time.  Particular  atten- 
tion, moreover,  should  then  be  paid  to  the  state  of  the  uterus.  Every 
means  should  be  taken  to  insure  regular  and  strong  contraction,  and 
it  is  advisable  to  rupture  the  membranes  early,  as  soon  as  the  os  is 
dilated  or  dilatable,  to  insure  stronger  uterine  action.  If  any  tend- 
ency to  relaxation  occur  after  delivery,  a  piece  of  ice  should  be 
passed  into  the  vagina,  or  into  the  uterus.  Should  coagula  collect 
in  the  uterus,  they  may  be  readily  expelled  by  firm  pressure  on  the 
fundus,  and  the  finger  should  be  passed  occasionally  up  to  the  cervix, 
and  any  which  are  felt  there  should  be  gently  picked  away. 

We  should  be  specially  on  our  guard  in  all  cases  in  which  the 
pulse  does  not  fall  after  delivery.  If  it  beat  at  100  or  more  some 
ten  minutes  or  a  quarter  of  an  hour  after  the  birth  of  the  child, 
hemorrhage  not  unfrequently  follows;  and,  hence,  it  is  a  good  prac- 
tical rule,  which  may  save  much  trouble,  that  a  patient  should  never 
be  left  unless  the  pulse  has  fallen  to  its  natural  standard. 

Curative  Treatment. — As  there  are  only  two  means  which  nature 
adopts  in  the  prevention  of  post-partum  hemorrhage,  so  the  remedial 
measures  also  may  be  divided  into  two  classes.  1.  Those  which  act 
by  the  production  of  uterine  contraction.  2.  Those  which  act  by 
producing  thrombosis  in  the  vessels.  Of  these  the  first  are  the  most 
commonly  used ;  and  it  is  only  in  the  worst  cases,  in  which  they  have 
been  assiduously  tried  and  have  failed,  that  we  resort  to  those  coming 
under  the  second  heading. 

Uterine  Pressure. — The  patient  should  be  placed  on  her  back,  in 
which  position  we  can  more  readily  command  the  uterus,  as  well  as 
attend  to  her  general  state.  If  the  uterus  be  found  relaxed  and  full 
of  clots,  by  firmly  grasping  it  in  the  hand  contraction  may  be  evoked, 
its  contents  expelled,  and  further  hemorrhage  at  once  arrested.  Should 
this  fortunately  be  the  case,  we  must  keep  up  contraction  by  gently 
kneading  the  uterus,  until  we  are  satisfied  that  undue  relaxation  will 
not  recur.  The  powerful  influence  of  friction  in  promoting  contrac- 
tion cannot  be  doubted,  and  nothing  will  replace  it;  no  doubt  it  is 
fatiguing,  but  as  long  as  it  is  effectual  it  must  be  kept  up.  No 
roughness  should  be  used,  as  we  might  produce  subsequent  injury, 
but  it  is  quite  possible  to  use  considerable  pressure  without  any 
violence. 

Another  method  of  applying  uterine  pressure  has  been  strongly 
27 


410  LABOR. 

advocated  by  Dr.  Hamilton,  of  Falkirk,  and  it  may  be  serviceable 
where  there  is  a  constant  draining  from  the  uterus,  and  a  capacious 
pelvis.  It  consists  in  passing  the  fingers  of  the  right  hand  high  up 
in  the  posterior  cul  de  sac  of  the  vagina,  so  as  to  reach  the  posterior 
surface  of  the  uterus,  while  counter-pressure  is  exercised  by  the  left 
hand  through  the  abdomen.  The  anterior  and  posterior  walls  of  the 
uterus  are  thus  closely  pressed  together. 

Administration  of  .Ergot. — During  the  time  that  pressure  is  being 
applied,  attention  can  be  paid  to  general  treatment;  and  in  giving 
his  directions  to  the  bystanders  the  practitioner  should  be  cairn  and 
collected,  avoiding  all  hurry  and  excitement.  A  full  dose  of  ergot 
should  be  administered,  and  if  one  have  already  been  given,  it  should 
be  repeated.  We  cannot,  however,  look  upon  ergot  as  anything  but  a 
useful  accessory,  and  it  is  one  which  requires  considerable  time  to 
operate.  The  hypodermic  use  of  ergotine  offers  the  double  advan- 
tage, in  severe  cases,  of  acting  with  greater  power,  and  much  more 
rapidly  than  the  usual  method  of  administration.  It  should,  there- 
fore, always  be  used  in  preference. 

Stimulants. — The  sudden  flow  will  probably  have  produced  ex- 
haustion and  a  tendency  to  syncope,  and  the  administration  of  stimu- 
lants will  be  necessary.  The  amount  must  be  regulated  by  the  state 
of  the  pulse,  and  the  degree  of  exhaustion.  There  is  no  more  ab- 
surd mistake,  however,  than  implicitly  relying  on  the  brandy  bottle 
to  check  post-parturn  hemorrhage.  In  the  worst  cases  absorption  is 
in  abeyance,  and  brandy  may  be  poured  down  in  abundance,  the  prac- 
titioner believing  that  he  is  rousing  his  patient,  while  he  is,  in  fact, 
merely  filling  the  stomach  with  a  quantity  of  fluid,  which  is  eventu- 
ally thrown  up  unaltered.  I  have  more  than  once  seen  symptoms, 
produced  from  the  over-free  use  of  brandy  in  slight  floodings,  which 
were  certainly  not  those  of  hemorrhage.  I  remember  on  one  occa- 
sion being  summoned  by  a  practitioner,  with  a  view  to  transfusion, 
to  a  patient  who  was  said  to  be  insensible  and  collapsed  from  hemor- 
rhage. I  found  her.  indeed,  unconscious ;  but  with  a  flushed  face,  a 
bounding  pulse,  a  firmly  contracted  uterus,  and  deep  stertorous 
breathing.  On  inquiry  I  ascertained  that  she  had  taken  an  enor- 
mous quantity  of  brandy,  which  had  brought  on  the  coma  of  pro- 
found intoxication,  while  the  hemorrhage  had  obviously  never  been 
excessive. 

Hypodermic  Injection  of  Ether. — The  hypodermic  injection  of  sul- 
phuric ether  has  been  recommended  as  a  powerful  stimulant  in 
cases  in  which  exhaustion  is  very  great.  A  fluidrachrn  may  be  in- 
jected, and  the  remedy  is  worthy  of  trial,  when  the  tendency  to  syn- 
cope is  extreme. 

Fresh  Air,  etc. — The  windows  should  be  thrown  widely  open,  to 
allow  a  current  of  fresh  cold  air  to  circulate  freely  through  the  room. 
The  pillows  should  be  removed,  the  head  kept  low,  and  the  patient 
should  be  assiduously  fanned. 

Emptying  of  Uterus. — If  bleeding  continue,  or  if  it  commence  be- 
fore the  placenta  is  expelled,  the  hand  should  be  carefully  and  gently 
passed  into  the  uterus,  and  its  cavity  cleared  of  its  contents.  The 


HEMORRHAGE    AFTER    DELIVERY.  411 

mere  presence  of  the  hand  within  the  uterus  is  a  powerful  incitor  of 
uterine  action.  When  the  placenta  is  retained  it  is  the  more  essen- 
tial, as  the  hemorrhage  cannot  possibly  be  checked  as  long  as  the 
uterus  is  distended  by  it.  During  the  operation  the  uterus  should 
be  supported  by  the  left  hand  externally,  and,  by  using  the  two 
hands  in  concert,  the  chances  of  injuring  the  textures  are  greatly 
lessened. 

Treatment  of  Hour-glass  Contraction. — If  the  so-called  "hour  glass 
contraction"  be  present,  or  if  the  placenta  be  morbidly  adherent,  the 
operation  will  be  more  difficult,  and  will  require  much  judgment  and 
care.  The  spasmodic  contraction  of  the  inner  os  in  the  former  case 
may  generally  be  overcome  by  gentle  and  continuous  pressure  of  the 
fingers  passed  within  the  contraction,  while  the  uterus  is  supported 
from  without.  By  this  means,  too,  further  hemorrhage  can  in  most 
cases  be  controlled,  until  the  spasm  is  sufficiently  relaxed  to  admit  of 
the  passage  of  the  hand. 

Signs  of  Adherent  Placenta. — There  are  no  very  reliable  signs  to 
indicate  morbid  adhesion  of  the  placenta,  previous  to  the  introduc- 
tion of  the  hand.  The  following  are  the  symptoms  as  laid  down  by 
Barnes,  any  of  which  might,  however,  accompany  non-detachment  of 
the  placenta,  unaccompanied  by  adhesion  :  "  You  may  suspect  mor- 
bid adhesion,  if  there  have  been  unusual  difficulty  in  removing  the 
placenta  in  previous  labors;  if,  during  the  third  stage,  the  uterus 
contracts  at  intervals  firmly,  each  contraction  being  accompanied  by 
blood,  and  yet,  on  following  up  the  cord,  you  feel  the  placenta  in 
utero ;  if  on  pulling  on  the  cord,  two  fingers  being  pressed  into  the 
placenta  at  the  root,  you  feel  the  placenta  and  uterus  descend  in  one 
mass,  a  sense  of  dragging  pain  being  elicited ;  if,  during  a  pain  the 
uterine  tumor  does  not  present  a  globular  form,  but  be  more  promi- 
nent than  usual  at  the  place  of  placenta!  attachment."1 

Treatment  of  Adherent  Placenta. — The  artificial  removal  of  an  ad- 
herent placenta  is  always  a  delicate  and  anxious  operation,  which, 
however  carefully  performed,  must  of  necessity  expose  the  patient 
to  the  risk  of  injury  to  the  uterine  structures,  and  of  leaving  behind 
portions  of  placental  tissue,  which  may  give  rise  to  secondary  hemor- 
rhage, or  septicaemia.  The  cord  will  guide  the  hand  to  the  site  of 
attachment,  and  the  fingers  must  be  very  gently  insinuated  between 
the  lower  edge  of  the  placenta  and  the  uterine  wall ;  or,  if  a  portion 
be  already  detached,  we  may  commence  to  peel  off  the  remainder  at 
that  spot.  Supporting  the  uterus  externally,  we  carefully  pick  off  as 
much  as  possible,  proceeding  with  the  greatest  caution,  as  it  is  by  no 
means  easy  to  distinguish  between  the  placenta  and  the  uterus.  At 
the  best  it  is  far  from  easy  to  remove  all,  and  it  is  wiser  to  separate 
only  what  we  readily  can,  than  to  make  too  protracted  efforts  at  com- 
plete detachment.  When  it  is  found  to  be  impossible  to  detach  and 
remove  the  whole,  or  a  great  part  of  the  placenta,  we  cannot  but 
look  upon  the  further  progress  of  the  case  with  considerable  anxiety. 
The  retained  portions  may  be,  ere  long,  spontaneously  detached  and 

1  Obstetric  Operations,  p.  440. 


412  LABOR. 

expelled,  or  they  may  decompose  and  give  rise  to  fetid  discharge 
and  septic  infection.  Such  cases  must  be  treated  by  antiseptic  intra- 
uterine  injections,  so  as  to  lessen  the  risk  of  absorption  as  much  as 
possible ;  but  until  the  retained  masses  have  been  expelled,  and  the 
discharge  has  ceased,  the  patient  must  be  considered  to  be  in  consider- 
able danger.  In  a  few  rare  cases,  there  is  reason  to  believe  that 
considerable  masses  of  retained  placental  tissue  have  been  entirely 
absorbed.  It  is  difficult  to  understand  so  strange  a  phenomenon, 
but  several  well-authenticated  cases  are  recorded,  in  \vhieh  there 
seems  no  reason  to  doubt  that  the  retained  placenta  was  removed  in 
this  way.1 

Excitement  of  Reflex  Action  l>y  Cold,  etc. — Various  means  are  used 
for  exciting  uterine  contraction  by  reflex  stimulation.  Amongst  the 
most  important  of  these  is  cold.  In  patients  who  are  not  too  ex- 
hausted to  respond  to  the  stimulus  applied,  it  is  of  extreme  value. 
But,  to  be  of  use,  it  should  be  used  intermittently,  and  not  continu- 
ously. Pouring  a  stream  of  cold  water  from  a  height  on  the  abdomen 
is  a  not  uncommon,  but  bad,  practice,  as  it  deluges  the  patient  and 
the  bedding  in  water,  which  may  afterwards  act  injuriously.  Flap- 
ping the  lower  part  of  the  abdomen  with  a  wet  towel  is  less  objec- 
tionable. Ice  can  generally  be  obtained,  and  a  piece  should  be  in- 
troduced into  the  uterus.  This  is  a  very  powerful  haemostatic,  and 
often  excites  strong  action  when  other  means  fail.  I  constantly  em- 
ploy it,  and  have  never  seen  any  bad  results  follow.  A  large  piece 
of  ice  may  also  be  held  over  the  fundus,  and  removed,  and  re-applied 
from  time  to  time.  Iced  water  may  be  injected  into  the  rectum.  A 
very  powerful  remedy  is  washing  out  the  uterine  cavity  with  a 
stream  of  cold  water,  by  means  of  the  vaginal  pipe  of  a  Higginson's 
syringe  carried  up  to  the  fundus.  Another  means  of  applying  cold, 
said  to  be  very  effectual,  is  the  application  of  the  ether  spray,  such  as 
is  used  for  producing  local  anaesthesia,  over  the  lower  part  of  the 
abdomen.2  All  these  remedies,  however,  depend  for  their  good  re 
suits  on  the  fact  of  the  patient  being  in  a  condition  to  respond  to 
stimulus  ;  and  their  prolonged  use,  if  they  fail  to  excite  contraction 
rapidly,  will  certainly  prove  injurious.  Rigby  used  to  look  upon  the 
application  of  the  child  to  the  breast  as  one  of  the  most  certain  in- 
citors  of  uterine  action.  It  may  be  of  service,  after  the  hemor- 
rhage has  been  checked,  in  keeping  up  tonic  contraction,  and  should 
therefore  not  be  omitted;  but  we  certainly  cannot  waste  time  in  in- 
ducing the  child  to  suck  in  the  face  of  the  actual  emergency. 

Intra-uterine  Injections  of  Warm  Water. — Of  late,  intra-uterine  in- 
jections of  warm  water,  at  a  temperature  of  from  110°  to  120°,  have 
been  highly  recommended  as  a  powerful  means  of  arresting  post- 
p&rtum  hemorrhage,  often  proving  effectual  when  all  other  treatment 
has  failed.  The  number  of  published  cases  in  which  it  has  proved 
of  great  value  is  now  considerable.  The  present  master  of  the 

1  See  an  interesting  paper  by  Dr.  Thrush  on  "  Retention  of  the  Placenta  in  Labor 
at  Tenn."     Am.  Journ.  of  Obstet.,  July,  1877. 
*  Griffiths,  Practitioner,  March,  1877. 


HEMORRHAGE    AFTER    DELIVERY.  413 

Kotunda,  Dr.  Lombe  Atthill,  has  recorded  16  cases1  in  wliicli  it 
checked  hemorrhage  at  once,  in  many  of  which  ergot,  ice,  and  other 
means  had  failed.  He  speaks  of  it  as  especially  useful  in  those 
troublesome  cases  in  which  the  uterus  alternately  relaxes  and 
hardens,  and  resists  all  our  efforts  to  produce  permanent  contraction. 
My  own  experience  of  this  treatment  is  too  limited  to  justify  my 
giving  a  decided  opinion  on  its  merits;  but  I  have  tried  it  in  two  or 
three  cases,  and  in  them  the  result  certainly  exceeded  my  expecta- 
tions. I  think  it  cannot  be  doubted  that  we  have  in  these  warm 
irrigations  a  valuable  addition  to  our  methods  of  treating  uterine 
hemorrhage. 

State  of  the  Bladder, — The  late  Dr.  Earle  pointed  out2  that  a  dis- 
tended bladder  often  prevents  contraction,  and  to  avoid  the  possi- 
bility of  this  the  catheter  should  be  passed. 

Plugging  the  Vayina. — Plugging  of  the  vagina  has  often  been 
used.  It  is  only  necessary  to  mention  it  for  the  purpose  of  insisting 
on  its  absolute  inapplicability  in  all  cases  of  post-partum  hemorrhage; 
the  only  effect  it  could  have  would  be  to  prevent  the  escape  of  blood 
externally,  which  might  then  collect  to  any  extent  in  the  cavity  of 
the  uterus. 

Compression  of  the  abdominal  aorta  is  highly  thought  of  by  many 
continental  authorities,  but  is  little  known  or  practised  in  this 
country.  It  has  been  objected  to  by  some  on  the  theoretical  ground 
that  the  hemorrhage  is  chiefly  venous,  and  not  arterial,  and  that  it 
would  only  favor  the  reflux  of  venous  blood  into  the  vena  cava. 
Cazeaux  points  out  that,  on  account  of  the  close  anatomical  relations 
between  the  aorta  and  the  vena  cava,  it  is  hardly  possible  to  compress 
one  vessel  without  the  other.  The  backward  flow  of  blood,  therefore, 
through  the  vena  -cava  may  also  be  thus  arrested.  There  is  strong 
evidence  in  favor  of  the  occasional  utility  of  compression.  Its  chief 
recommendation  is,  that  it  can  be  practised  immediately,  and  by  an 
assistant  who  can  be  shown  how  to  apply  the  pressure.  It  is  most 
likely  to  prove  useful  in  sudden  and  severe  hemorrhage,  and,  if  it 
only  control  the  loss  for  a  few  moments,  it  gives  us  time  to  apply 
other  methods  of  treatment.  As  a  temporary  expedient,  therefore, 
it  should  be  borne  in  mind,  and  adopted  when  necessary.  It  has 
the  great  advantage  of  supplementing,  without  superseding,  other 
and  more  radical  plans  of  treatment.  The  pressure  is  very  easily 
applied,  on  account  of  the  lax  state  of  the  abdominal  walls.  The 
artery  can  readily  be  felt  pulsating  above  the  fundus  uteri,  and  can 
be  compressed  against  the  vertebrae  by  three  or  four  fingers  applied 
lengthways.  Baudelocque,  who  was  a  strong  advocate  of  this  pro- 
cedure, states  that  he  has,  on  several  occasions,  controlled  an  other- 
wise intractable  hemorrhage  in  this  way,  and  that  he,  on  one  occasion, 
kept  up  compression  for  four  consecutive  hours.  Cazeaux  believes 
that  compression  of  the  aorta  may  have  a  further  advantageous  effect 
in  retaining  the  mass  of  the  blood  in  the  upper  part  of  the  body,  and 
thus  lessening  the  tendency  to  syncope  and  collapse.  If  an  aortic 

1  Lancet,  February  9,  1878.  2  Earle's  Flooding  after  Delivery,  p.  1C3. 


414  LABOR. 

tourniquet,  such  as  is  used  for  compressing  the  vessel  in  cases  of 
aneurism,  could  be  obtained,  it  might  be  used  with  advantage  in 
serious  cases. 

Bandaging  of  the  Extremities. — When  the  hemorrhage  has  been 
excessive,  and  there  is  profound  exhaustion,  firm  bandaging  of  the 
extremities,  by  preference  with  Esmarch's  elastic  bandages  if  they 
can  be  obtained,  may  be  advantageously  adopted,  with  the  view  of 
retaining  the  blood  as  much  as  possible  in  the  trunk,  and  thus  lessen- 
ing the  tendency  to  syncope.  As  a  temporary  expedient  in  the 
worst  class  of  cases  it  may  occasionally  prove  of  service. 

Injection  of  /Styptics. — Supposing  these  means  fail,  and  the  uterus 
obstinately  refuses  to  contract  in  spite  of  all  our  efforts — and,  do 
what  we  may,  cases  of  this  kind  will  occur — the  only  other  agent  at 
our  command  is  the  application  of  a  powerful  styptic  to  the  bleeding 
surface  to  produce  thrombosis  in  the  vessels.  "The  latter,"  says  Dr. 
Ferguson,1  alluding  to  this  means  of  arresting  hemorrhage,  "appears 
to  be  the  sole  means  of  safety  in  those  cases  of  intense  flooding  in 
which  the  uterus  flaps  about  the  hand  like  a  wet  towel.  Incapable 
of  contraction  for  hours,  yet  ceasing  to  ooze  out  a  drop  of  blood, 
there  is  nothing  apparently  between  life  and  death  but  a  few  soft 
coagula  plugging  up  the  sinuses."  These  form  but  a  frail  barrier 
indeed,  but  the  experience  of  all  who  have  used  the  injection  of  a 
solution  of  perchloride  of  iron  in  such  cases,  proves  that  they  are 
thoroughly  effectual,  and  its  introduction  into  practice  is  one  of  the 
greatest  improvements  in  modern  midwifery.  Although  this  method 
of  treating  these  obstinate  cases  is  not  new,  since  it  was  practised 
long  ago  in  Germany,  its  adoption  in  this  country  is  unquestionably 
due  to  the  energetic  recommendation  of  Dr.  Barnes.  Although  the 
dangers  of  the  practice  have  been  strongly  insisted  on,  and  with  a 
degree  of  acrimony  that  is  to  be  regretted,  I  know  of  only  one  pub- 
lished case  in  which  its  use  has  been  followed  by  any  evil  effects. 
Its  extraordinary  power,  however,  of  instantly  checking  the  most 
formidable  hemorrhage,  has  been  demonstrated  by  the  unanimous 
testimony  of  all  who  have  tried  it.  As  it  is  not  proposed  by  any  one 
that  this  means  of  treatment  should  be  employed  until  all  ordinary 
methods  of  evoking  contraction  have  failed,  and  as,  in  cases  of  this 
kind,  the  lives  of  the  patients  are  of  necessity  imperilled,  we  should 
be  fully  justified  in  adopting  it,  even  if  its  possible  injurious  effects 
had  been  much  more  certainly  proved.  It  is  surely  at  any  time 
justifiable  to  avoid  a  great  and  pressing  peril  by  running  a  possible 
chance  of  a  less  one.  Whenever,  therefore,  we  have  tried  the  plans 
above  indicated  in  vain,  no  time  should  be  lost  in  resorting  to  this 
expedient.  No  practitioner  should  attend  a  case  of  midwifery  with- 
out having  the  necessary  styptic  with  him.  The  best  and  most 
easily  obtainable  form  of  using  the  remedy  is  the  "liquor  ferri  per- 
chloridi  fortior"  of  the  London  Pharmacopoeia,  which  should  be 
diluted  for  use  with  six  times  its  bulk  of  water.  This  is  certainly 
better  than  a  weaker  solution.  The  vaginal  pipe  of  a  Higginson's 

1  Preface  to  Gooch  On  Diseases  of  Women,  p.  xlii. 


HEMORRHAGE    AFTER    DELIVERY.  415 

syringe,  through  which  the  solution  has  once  or  twice  been  pumped 
to  exclude  the  air,  is  guided  by  the  hand  to  the  fundus  uteri,  and 
the  fluid  injected  gently  over  the  uterine  surface.  The  loose  and 
flabby  mucous  membrane  is  instantaneously  felt  to  pucker  up,  all 
the  blood  with  which  the  fluid  comes  in  contact  is  coagulated,  and 
the  hemorrhage  is  immediately  arrested.  I  think  it  is  of  importance 
to  make  sure  that  the  uterus  and  vagina  are  emptied  of  clots  before 
injection.  In  the  only  case  in  which  I  have  seen  any  bad  symptoms 
follow,  this  precaution  had  been  neglected.  The  iron  hardened  all 
the  coagula,  which  remained  in  utero,  and  septicaemia  supervened; 
which,  however,  disappeared  after  the  clots  had  been  broken  up  and 
washed  away  by  intra-uterine  antiseptic  injections.  After  we  have 
resorted  to  this  treatment,  all  further  pressure  on  the  uterus  should 
be  stopped.  We  must  remember  that  we  have  now  abandoned  con- 
traction as  an  hasmostatic,  and  are  trusting  to  thrombosis,  and  that 
pressure  might  detach  and  lessen  the  coagula  which  are  preventing 
the  escape  of  blood. 

Other  local  astringents  may  be  eventually  found  to  be  of  use. 
Tincture  of  matico  possibly  might  be  serviceable,  although  I  am  not 
aware  that  it  has  been  tried.  Dupierris  has  advocated  tincture  of 
iodine,  and  has  recorded  24  cases  in  which  he  employed  it,  in  all 
without  accident  and  with  a  successful  issue.  But  nothing  seems 
likely  to  act  so  immediately,  or  so  effectually,  as  the  perchloride  of 
iron. 

Hemorrhage  from  Laceration  of  Maternal  Structures. — A  word 
may  here  be  said  as  to  the  occasional  dependence  of  hemorrhage 
after  delivery  on  laceration  of  the  cervix,  or  other  injury  to  the 
maternal  soft  parts.  Duncan  has  narrated  a  case  in  which  the  bleed- 
ing came  from  a  ruptured  perineum.  If  hemorrhage  continue  after 
the  uterus  is  permanently  contracted,  a  careful  examination  should 
be  made  to  ascertain  if  any  such  injury  exist.  Most  generally  the 
source  of  bleeding  is  the  cervix,  and  the  flow  can  be  readily  arrested 
by  swabbing  the  injured  textures  with  a  sponge  saturated  in  a  solu- 
tion of  the  perchloride. 

Secondary  Treatment. — The  secondary  treatment  of  post-partum 
hemorrhage  is  of  importance.  When  reaction  commences,  a  train 
of  distressing  symptoms  often  show  themselves,  such  as  intense  and 
throbbing  headache,  great  intolerance  of  light  and  sound,  and  general 
•nervous  prostration;  and,  when  these  have  passed  away,  we  have  to 
deal  with  the  more  chronic  effects  of  profuse  loss  of  blood.  Nothing 
is  so  valuable  in  relieving  these  symptoms  as  opium.  It  is  the  best 
restorative  that  can  be  employed,  but  it  must  be  administered  in 
larger  doses  than  usual.  Thirty  to  forty  drops  of  Battley's  solution 
should  be  given  by  the  mouth,  or  in  an  enema.  At  the  same  time 
the  patient  should  be  kept  perfectly  still  and  quiet,  in  a  darkened 
room,  and  the  visits  of  anxious  friends  strictly  forbidden.  Strong 
beef  essence,  or  gravy  soup,  milk,  or  eggs  beat  up  with  milk,  and 
similar  easily  absorbed  articles  of  diet,  should  be  given  frequently, 
and  in  small  quanties  at  a  time.  Stimulants  will  be  required  accord- 
ing to  the  state  of  the  patient,  such  as  warm  brandy  and  water,  port 


416  LABOR. 

wine,  etc.  Best  in  bed  should  be  insisted  on,  and  continued  much 
beyond  the  usual  time.  Eventually  the  remedies  which  act  by  pro- 
moting the  formation  of  blood,  such  as  the  various  preparations  of 
iron,  will  be  found  useful,  and  may  be  required  for  a  length  of  time. 

Transfusion. — Under  the  head  of  transfusion  I  have  separately 
treated  the  application  of  that  last  resource  in  those  desperate  cases 
in  which  the  loss  of  blood  has  been  so  excessive  as  to  leave  no  other 
hope. 

Secondary  Post-partum  Hemorrhage. — In  the  majority  of  cases,  if 
a  few  hours  have  elapsed  after  delivery  without  hemorrhage,  we 
may  consider  the  patient  safe  from  the  accident.  It  is  by  no  means 
very  rare,  however,  to  meet  with  even  profuse  losses  of  blood  corning 
on  in  the  course  of  convalescence,  at  a  time  varying  from  a  few  hours, 
or  days,  up  to  several  weeks  after  delivery.  These  cases  are  described 
as  examples  of  "secondary  hemorrhage"  and  they  have  not  received 
at  all  an  adequate  amount  of  attention  from  obstetric  writers,  inas- 
much as  they  often  give  rise  to  very  serious,  and  even  fatal,  results, 
and  are  always  somewhat  obscure  in  their  etiology,  and  difficult  to 
treat.  We  owe  almost  all  our  knowledge  of  this  condition  to  an 
excellent  paper  by  Dr.  McClintock,  of  Dublin,  who  has  collected 
characteristic  examples  from  the  writings  of  various  authors,  and 
accurately  described  the  causes  which  are  most  apt  to  produce  it. 

Profuse  Lochial  Discharge. — We  must,  in  the  first  place,  distin- 
guish between  true  secondary  hemorrhage  and  profuse  lochial  dis- 
charge, continued  for  a  longer  time  than  usual.  The  latter  is  not  a 
very  uncommon  occurrence,  and  is  generally  met  with  in  cases  in 
which  involution  of  the  uterus  has  been  checked;  as  by  too  early 
exertion,  general  debility,  and  the  like.  The  amount  of  the  lochial 
discharge  varies  in  different  women.  In  some  patients  it  habitually 
continues  during  the  whole  puerperal  month,  and  even  longer,  but 
not  to  an  extent  which  justifies  us  in  including  it  under  the  head  of 
hemorrhage.  In  such  cases  prolonged  rest,  avoidance  of  the  erect 
posture,  occasional  small  doses  of  ergot,  and,  it  may  be,  after  the 
lapse  of  some  weeks,  astringent  injections  of  oak  bark,  or  alum,  will 
be  all  that  is  necessary  in  the  way  of  treatment. 

True  secondary  hemorrhage  is  often  sudden  in  its  appearance  and 
serious  in  its  effects.  McClintock  mentions  6  fatal  cases,  and  Mr, 
Bassett,  of  Birmingham,1  has  recorded  13  examples  which  came 
under  his  own  observation,  2  of  which  ended  fatally. 

The  Causes  are  either  Constitutional  or  Local. — The  causes  may  be 
either  constitutional,  or  some  local  condition  of  the  uterus  itself. 

Among  the  former  are  such  as  produce  a  disturbance  of  the  vas- 
cular system  of  the  body  generally,  or  of  the  uterine  vessels  in 
particular.  The  state  of  the  uterine  sinuses,  and  the  slight  barrier 
which  the  thrombi  formed  in  them  offer  to  the  escape  of  blood,  readily 
explain  the  fact  of  any  sudden  vascular  congestion  producing  hemor- 
rhage. Thus  mental  emotions,  the  sudden  assumption  of  the  erect 
posture,  any  undue  exertion,  the  incautious  use  of  stimulants,  a 

1  Brit.  Med  Jour.,  1872. 


HEMORRHAGE    AFTER    DELIVERY.  417 

loaded  condition  of  the  bowels,  or  sexual  intercourse  shortly  after 
delivery,  may  act  in  this  way.  McClintock  records  the  case  of  a 
lady  in  whom  very  profuse  hemorrhage  occurred  on  the  twelfth  day 
after  labor,  when  sitting  up  for  the  first  time.  Feeling  faint  after 
suckling,  the  nurse  gave  her  some  brandy,  whereupon  a  gush  of 
blood  ensued,  "deluging  all  the  bed-clothes  and  penetrating  through 
the  mattress  so  as  to  form  a  pool  on  the  floor."  Here  the  erect  posi- 
tion, the  exquisite  pain  caused  by  nursing,  and  the  stimulating  drink, 
all  concurred  to  excite  the  hemorrhage.  In  another  instance  the 
flooding  was  traced  to  excitement  produced  by  the  sudden  return  of 
an  old  lover  on  the  eighth  day  after  labor.  Moreau  especially  dwells 
on  the  influence  of  local  congestion  produced  by  a  loaded  condition 
of  the  rectum.  Constitutional  affections  producing  general  debility, 
and  an  impoverished  state  of  the  blood,  probably  also  may  have  the 
same  effect.  Blot  specially  mentions  albumin  aria  as  one  of  these, 
and  Saboia  states  that  in  Brazil  secondary  hemorrhage  is  a  common 
symptom  of  miasmatic  poisoning,  and  can  only  be  cured  by  change 
of  air  and  the  free  use  of  quinine.1 

Local  Causes. — Local  conditions  seem,  however,  to  be  more  fre- 
quent factors  in  the  production  of  secondary  hemorrhage.  These 
may  be  generally  classed  under  the  following  heads: — 

1.  Irregular  and  inefficient  contraction  of  the  uterus. 

2.  Clots  in  the  uterine  cavity. 

3.  Portions  of  retained  placenta  or  membranes. 

4.  Retroflexion  of  the  uterus. 

5.  Laceration  or  inflammatory  state  of  the  cervix. 

6.  Thrombosis  or  haematocele  of  the  cervix  or  vulva. 

7.  Inversion  of  the  uterus. 

8.  Fibroid  tumors  or  polypus  of  the  uterus. 

The  first  four  of  these  need  only  now  be  considered,  the  others 
being  described  elsewhere. 

Relaxation  of,  and  Clots  in,  the  Uterus. — Relaxation  of  the  uterus 
and  distension  of  its  cavity  by  coagula  may  give  rise  to  hemorrhage, 
although  not  so  readily  as  immediately  after  delivery,  for  coagula  of 
considerable  size  are  often  retained  in  utero  for  many  days  after 
labor.  The  uterus  will  be  found  larger  than  it  ought  to  be,  and 
tender  on  pressure.  Usually  the  coagula  are  expelled  with  severe 
after-pains;  but  this  may  not  take  place,  and  hemorrhage  may  ensue 
several  days  after  delivery.  Or  there  may  be  only  a  relaxed  state 
of  the  uterus  without  retained  coagula.  Bassett  relates  4  cases  traced 
to  these  -causes,  and  several  illustrations  will  be  found  in  McClin- 
tock's  paper.  Portions  of  retained  placenta  or  membranes  are  more 
frequent  causes.  The  retention  may  be  due  to  carelessness  on  the 
part  of  the  practitioner,  especially  if  he  have  removed  the  placenta 
by  traction,  and  failed  to  satisfy  himself  of  its  integrity.  It  may, 
however,  often  be  due  to  circumstances  entirely  beyond  his  control; 
such  as  adherent  placenta,  which  it  is  impossible  to  remove  without 

1  Saboia,  Trait6  des  Accouchements,  p.  819. 


418  LABOR. 

leaving  portions  in  utero,  or  more  rarely  placenta  succenturia.  In 
the  latter  case  there  is  a  small  supplementary  portion  of  placental 
tissue  developed  entirely  separate  from  the  general  mass,  and  it  may 
remain  in  utero  without  the  practitioner  having  the  least  suspicion 
of  its  existence.  Portions  of  the  membranes  are  very  apt  to  be  left 
in  utero.  It  is  to  prevent  this  that  they  should  be  twisted  into  a 
rope,  and  extracted  very  gently  after  expression  of  the  placenta. 
Hemorrhage  from  these  causes  generally  does  not  occur  until  at  least 
a  week  after  delivery,  and  it  may  not  do  so  until  a  much  longer  time 
has  elapsed.  In  4  cases,  recorded  by  Mr.  Bassett,  it  commenced  on 
the  twelfth,  tenth,  fourteenth,  and  thirty-second  day.  It  may  come 
on  suddenly  and  continue ;  or  it  may  stop,  and  recur  frequently  at 
short  intervals.  In  my  experience  retention  of  portions  of  the  pla- 
centa is  very  common  after  abortion,  when  adhesions  are  more  gene- 
rally met  with  than  at  term.  In  addition  to  the  hemorrhage  there 
is  often  a  fetid  discharge,  due  to  decomposition  of  the  retained  por- 
tion, and  possibly  more  or  less  marked  septicsemic  symptoms,  which 
may  aid  in  the  diagnosis.  The  placenta  or  membranes  may  simply 
be  lying  loose  as  foreign  bodies  in  the  uterine  cavity ;  or  they  may 
be  organically  attached  to  the  uterine  walls,  when  their  removal  will 
not  be  so  easily  effected. 

Retroflexion. — Barnes  has  especially  pointed  out  the  influence  of 
retroflexion  of  the  uterus  in  producing  secondary  hemorrhage,1  which 
seems  to  act  by  impeding  the  circulation  at  the  point  of  flexion,  and 
thus  arresting  the  process  of  involution. 

In  every  case  in  which  secondary  hemorrhage  occurs  to  any  extent, 
careful  investigation  into  the  possible  causes  of  the  attack,  and  an 
accurate  vaginal  examination,  are  imperatively  required.  If  it  be 
due  to  general  and  constitutional  causes  only,  we  must  insist  on  the 
most  absolute  rest  on  a  hard  bed  in  a  cool  room,  and  on  the  absence 
of  all  causes  of  excitement.  The  liquid  extract  of  ergot  will  be  very 
generally  useful  in  3j  doses  repeated  every  six  hours.  McClintock 
strongly  recommends  the  tincture  of  Indian  hemp,  which  may  be  ad- 
vantageously combined  with  the  ergot,  in  doses  of  10  or  15  minims, 
suspended  in  mucilage.  Astringent  vaginal  pessaries  of  matico  or 
perchloride  of  iron  may  be  used.  Special  attention  should  be  paid 
to  the  state  of  the  bowels,  and,  if  the  rectum  be  loaded,  it  should  be 
emptied  by  enemata.  In  more  chronic  cases  a  mixture  of  ergot, 
sulphate  of  iron,  and  small  doses  of  sulphate  of  magnesia,  will  prove 
very  serviceable.  This  is  more  likely  to  be  effectual  when  the  bleed- 
ing is  of  an  atonic  and  passive  character.  McClintock  speaks  strongly 
in  favor  of  the  application  of  a  blister  over  the  sacrum.  When  the 
hemorrhage  is  excessive,  more  effectual  local  treatment  will  be  re- 
quired. Cazeaux  advises  plugging  of  the  vagina.  Although  this 
cannot  be  considered  so  dangerous  as  immediately  after  delivery, 
inasmuch  as  the  uterus  is  not  so  likely  to  dilate  above  the  plug, 
still  it  is  certainly  not  entirely  without  risk  of  favoring  concealed 
internal  hemorrhage.  If  it  be  used  at  all,  a  firm  abdominal  pad 

1  Obstetric  Operations,  p.  492. 


RUPTURE    OF    THE    UTERUS.  419 

should  be  applied,  so  as  to  compress  the  uterus;  and  the  abdomen 
should  be  examined,  from  time  to  time,  to  insure  against  the  possi- 
bility of  uterine  dilatation.  With  these  precautions  the  plug  may 
prove  of  real  value.  In  any  ease  of  really  alarming  hemorrhage  I 
should  be  disposed  rather  to  trust  to  the  application  of  styptics  to 
the  uterine  cavity.  The  injection  of  fluid  in  bulk,  as  after  delivery, 
could  not  be  safely  practised,  on  account  of  the  closure  of  the  os  and 
the  contraction  of  the  uterus.  But  there  can  be  no  objection  to 
swabbing  out  the  uterine  cavity  with  a  small  piece  of  sponge  attached 
to  a  handle,  and  saturated  in  a  solution  of  the  perchloride  of  iron. 
There  are  few  cases  which  will  resist  this  treatment. 

If  we  have  reason  to  suspect  retained  placenta  or  membranes,  or 
if  the  hemorrhage  continue  or  recur  after  treatment,  a  careful  ex- 
ploration of  the  interior  of  the  womb  will  be  essential.  On  vaginal 
examination,  we  may  possibly  feel  a  portion  of  the  placenta  protrud- 
ing through  the  os,  which  can  then  be  removed  without  difficulty. 
If  the  os  be  closed,  it  must  be  dilated  with  sponge  or  laminaria  tents, 
or  by  a  small-sized  Barnes'  bag,  and  the  uterus  can  then  be  thoroughly 
explored.  This  ought  to  be  done  under  chloroform,  as  it  cannot  be 
effectually  accomplished  without  introducing  the  whole  hand  into 
the  vagina,  which  necessarily  causes  much  pain.  If  the  placenta  or 
membranes  be  loose  in  the  uterine  cavity,  they  rnay  be  removed  at 
once ;  or,  if  they  be  organically  attached,  they  may  be  carefully 
picked  off.  The  uterus  should  at  the  same  time,  and  as  long  as  the 
os  remains  patulous,  be  thoroughly  washed  out  with  Condy's  fluid 
and  water,  to  diminish  the  risk  of  septicaemia. 

Retroflexion  can  readily  be  detected  by  vaginal  examination,  and 
the  treatment  consists  in  careful  reposition  with  the  hand,  and  the 
application  of  a  large-sized  Hodges'  pessary. 

[In  managing  the  convalescence  after  excessive  hemorrhage  it  is 
of  great  importance  to  replace  the  loss  as  rapidly  as  possible,  in  order 
to  avoid  serious  diseases  resulting  from  exhaustion.  To  accomplish 
this,  we  are  usually  in  the  habit  of  giving  the  essence  of  from  three 
to  seven  pounds  of  beef  per  diem,  for  the  first  two  weeks,  and  have 
given  as  high  as  eleven.  It  is  remarkable  how  soon  this  restores  the 
health  and  strength  of  the  woman. — ED.] 


CHAPTER  XVI. 

RUPTURE    OF   THE   UTERUS,  ETC. 

RUPTURE  of  the  uterus  is  one  of  the  most  dangerous  accidents  of 
labor,  and  until  of  late  years  it  has  been  considered  almost  necessarily 
fatal,  and  beyond  the  reach  of  treatment.  Fortunately  it  is  not  of 


420  LABOR. 

very  frequent  occurrence,  although  the  published  statistics  vary  so 
much  that  it  is  by  no  means  easy  to  arrive  at  any  conclusion  on  this 
point.  The  explanation  is,  no  doubt,  that  many  of  the  tables  con- 
found partial  and  comparatively  unimportant  lacerations  of  the  cer- 
vix and  vagina,  with  rupture  of  the  body  and  fundus.  It  is  only  in 
large  lying-in  institutions,  where  the  results  of  cases  are  accurately 
recorded,  that  anything  like  reliable  statistics  can  be  gathered,  for 
in  private  practice  the  occurrence  of  so  lamentable  an  accident  is 
likely  to  remain  unpublished.  To  show  the  difference  between  the 
figures  given  by  authorities,  it  may  be  stated  that,  while  Burns  cal- 
culates the  proportion  to  be  1  in  940  labors,  Ingleby  fixes  it  as  1  in 
1300  or  1400,  Churchill  as  1  in  1331,  and  Lehmann  as  1  in  2433. 
Dr.  Jolly,  of  Paris,  has  published  an  excellent  thesis  containing  much 
valuable  information.1  He  finds  that  out  of  782,741  labors.  230  rup- 
tures, excluding  those  of  the  vagina  or  cervix,  occurred,  that  is  1  in 
3403. 

Seat  of  Rupture. — Lacerations  may  occur  in  any  part  of  the 
uterus — the  fundus,  the  body,  or  the  cervix.  Those  of  the  cervix 
are  comparatively  of  small  consequence,  and  occur,  to  a  slight  ex- 
tent, in  almost  all  first  labors.  Only  those  which  involve  the  supra- 
vaginal  portion  are  of  really  serious  import.  Euptures  of  the  upper 
part  of  the  uterus  are  much  less  frequent  than  of  the  portion  near 
the  cervix ;  partly,  no  doubt,  because  the  fundus  is  beyond  the  reach 
of  the  mechanical  causes  to  which  the  accident  can,  not  unfrequently, 
be  traced,  and  partly  because  the  lower  third  of  the  organ  is  apt  to 
be  compressed  between  the  presenting  part  and  the  bony  pelvis.  The 
site  of  placental  insertion  is  said  by  Madame  La  Chapelle  to  be  rarely 
involved  in  the  rupture,  but  it  does  not  always  escape,  as  numerous 
recorded  cases  prove.  The  most  frequent  seat  of  rupture  is  near  the 
junction  of  the  body  and  neck,  either  anteriorly  or  posteriorly,  op- 
posite the  sacrum,  or  behind  the  symphysis  pubis,  but  it  may  occur 
at  the  sides  of  the  lower  segment  of  the  uterus.  In  some  cases 
the  entire  cervix  has  been  torn  away,  and  separated  in  the  form  of 
a  ring. 

Rupture  may  be  Partial  or  Complete. — The  laceration  may  be 
partial  or  complete ;  the  latter  being  the  more  common.  The  mus- 
cular tissue  alone  may  be  torn,  the  peritoneal  coat  remaining  intact; 
or  the  converse  may  occur,  and  then  the  peritoneum  is  often  fissured 
in  various  directions,  the  muscular  coat  being  unimplicated.  The 
extent  of  the  injury  is  very  variable ;  in  some  cases  being  only  a 
slight  tear,  in  others  forming  a  large  aperture,  sufficiently  extensive 
to  allow  the  foetus  to  pass  into  the  abdominal  cavity.  The  direction 
of  the  laceration  is  as  variable  as  the  size,  but  it  is  more  frequently 
vertical  than  transverse  or  oblique.  The  edges  of  the  tear  are  irregu- 
lar and  jagged ;  probably  on  account  of  the  contraction  of  the  mus- 
cular fibres,  which  are  frequently  softened,  infiltrated  with  blood, 
and  even  gangrenous.  Large  quantities  of  extravasated  blood  will 

1  Rupture  uterine  pendant  le  Travail,  Paris,  1873. 


KUPTURE  OF  THE  UTERUS.  421 

be  found  in  the  peritoneal  cavity ;  such  hemorrhage,  indeed,  being 
one  of  the  most  important  sources  of  danger. 

Causes  are  either  Predisposing  or  Exciting. — The  causes  are  divided 
into  predisposing  and  exciting ;  and  the  progress  of  modern  research 
tends  more  and  more  to  the  conclusion  that  the  cause  which  leads  to 
the  laceration  could  only  have  operated  because  the  tissue  of  the 
uterus  was  in  a  state  predisposed  to  rupture,  and  that  it  Avould  have 
had  no  such  effect  on  a  perfectly  healthy  organ.  What  these  pre- 
disposing changes  are,  and  how  they  operate,  is  yet  far  from  being 
known,  and  the  subject  offers  a  fruitful  field  for  pathological  investi- 
gation. 

Said  to  be  more  Common  in  Multiparse. — It  is  generally  believed 
that  lacerations  are  more  common  in  multipart  than  in  primipara?. 
Tyler  Smith  contended  that  ruptures  are  relatively  as  common  in 
first  as  in  subsequent  labors.  Statistics  are  not  sufficiently  accurate 
or  extensive  to  justify  a  positive  conclusion,  but  it  is  reasonable  to 
suppose  that  the  pathological  changes,  presently  to  be  mentioned  as 
predisposing  to  laceration,  are  more  likely  to  be  met  with  in  women 
whose  uteri  have  frequently  undergone  the  alteration  attendant  on 
repeated  pregnancies.  Age  seems  to  have  considerable  influence,  as 
a  large  proportion  of  cases  have  occurred  in  women  between  thirty 
and  forty  years  of  age. 

Alterations  in  the  tissues  of  the  uterus  are  probably  of  very  great 
importance  in  predisposing  to  the  accident,  although  our  information 
on  this  point  is  far  from  accurate.  Among  these  are  morbid  states 
of  the  muscular  fibres,  the  result  of  blows  or  contusions  during  preg- 
nancy ;  premature  fatty  degeneration  of  the  muscular  tissues,  an 
anticipation,  as  it  were,  of  the  normal  involution  after  delivery ; 
fibroid  tumors,  or  malignant  infiltration  of  the  uterine  walls,  which 
either  produce  a  morbid  state  of  the  tissues,  or  act  as  an  impediment 
to  the  expulsion  of  the  foetus.  The  importance  of  such  changes  has 
been  specially  dwelt  on  by  Murphy  in  this  country,  and  by  Lehmann 
in  Germany,  and  it  is  impossible  not  to  concede  their  probable  influ- 
ence in  favoring  laceration.  However,  as  yet  these  views  are  founded 
more  on  reasonable  hypothesis  than  on  accurately  observed  patho- 
logical facts. 

Another  and  very  important  class  of  predisposing  causes  are  those 
which  lead  to  a  want  of  proper  proportion  between  the  pelvis  and 
the  foetus. 

Deformity  in  Pelvis  is  a  Frequent  Cause. — Deformity  of  the  pelvis 
has  been  very  frequently  met  with  in  cases  in  which  the  uterus  has 
ruptured.  Thus  out  of  19  cases,  carefully  recorded  by  Eadford,1  the 
pelvis  was  contracted  in  11,  or  more  than  one-half.  Radford  makes 
the  curious  observation  that  ruptures  seem  more  likely  to  occur 
when  the  deformity  is  only  slight ;  and  he  explains  this  by  supposing 
that  in  slight  deformities  the  lower  segment  of  the  uterus  engages 
in  the  brim,  and  is,  therefore,  much  subjected  to  compression,  while 
in  extreme  deformity  the  os  and  cervix  uteri  remain  above  the  brim, 

1  Obst.  Trans.,  vol.  viii. 


422  LABOR. 

the  body  and  fundus  of  tlie  uterus  hanging  down  between  the  thighs 
of  the  mother.  This  explanation  is  reasonable  ;  but  the  rarity  with 
which  ruptured  uterus  is  associated  with  extreme  pelvic  deformity 
may  rather  depend  on  the  infrequency  of  advanced  degrees  of  con- 
traction. 

Malpresentation. — Amongst  causes  of  disproportion  depending  on 
the  foetus  are  either  malpresentation,  in  which  the  pains  cannot  effect 
expulsion,  or  undue  size  of  the  presenting  part.  In  the  latter  way 
may  be  explained  the  observation  that  rupture  is  much  more  fre- 
quently met  with  male  than  with  female  children,  on  account,  no 
cloubt,  of  the  larger  size  of  the  head  in  the  former.  The  influence 
of  intra-uterine  hydrocephalus  was  first  prominently  pointed  out  by 
Sir  James  Simpson,1  who  states  that  out  of  74  cases  of  intra-uterine 
hydrocephalus  the  uterus  ruptured  in  16.  In  all  such  cases  of  dis- 
proportion, whether  referable  to  the  pelvis  or  foetus,  rupture  is  pro- 
duced in  a  twofold  manner,  either  by  the  excessive  and  fruitless 
uterine  contractions,  which  are  induced  by  the  efforts  of  the  organ 
to  overcome  the  obstacle ;  or  by  the  compression  of  the  uterine  tissue 
between  the  presenting  part  and  the  bony  pelvis,  leading  to  inflam- 
mation, softening,  and  even  gangrene. 

Mechanical  Injury  of  Rupture. — The  proximate  cause  of  rupture 
may  be  classed  under  two  heads — mechanical  injury,  and  excessive 
uterine  contraction.  Under  the  former  are  placed  those  uncommon 
cases  in  which  the  uterus  lacerates  as  the  result  of  some  injury  in 
the  latter  months  of  pregnancy,  such  as  blows,  falls,  and  the  like. 
Not  so  rare,  unfortunately,  are  lacerations  produced  by  unskilled 
attempts  at  delivery  on  the  part  of  the  medical  attendant,  such  as 
by  the  hand  during  turning,  or  by  the  blades  of  the  forceps.  Many 
such  cases  are  on  record,  in  which  the  accoucheur  has  used  force  and 
violence,  rather  than  skill,  in  his  attempts  to  overcome  an  obstacle. 
That  such  unhappy  results  of  ignorance  are  not  so  uncommon  as  they 
ought  to  be  is  proved  by  the  figures  of  Jolly,  who  has  collected  71 
cases  of  rupture  during  podalic  version, '37  caused  by  the  forceps,  10 
by  the  cephalotribe,  and  30  during  other  operations,  the  precise  nature 
of  which  is  not  stated.2  The  modus  operandi  of  protracted  and  in- 
effectual uterine  coutractions,  as  a  proximate  cause  of  rupture,  is 
sufficiently  evident,  and  need  not  be  dwelt  on.  It  is  necessary  to 
allude,  however  to  the  effect  of  ergot,  incautiously  administered,  as 
a  producing  cause.  There  is  abundant  evidence  that  the  injudicious 
exhibition  of  this  drug  has  often  been  followed  by  laceration  of  the 
unduly  stimulated  uterine  fibres.  Thus  Trask,  talking  of  the  sub- 
ject, says  that  Meigs  had  seen  three  cases,  and  Bedford  four,  distinctly 
traceable  to  this  cause.  Jolly  found  that  ergot  had  been  administered 
largely  in  33  cases  in  which  rupture  occurred. 

Premonitory  /Symptoms. — Some  have  believed  that  the  impending 
occurrence  of  rupture  could  frequently  be  ascertained  by  peciiliar 
premonitory  symptoms,  such  as  excessive  and  acute  crampy  pains 
about  the  lower  part  of  the  abdomen,  due  to  the  compression  of  part 

1  Selected  Obst.  Works,  p.  385.  2  Op.  cit.,  p.  38. 


RUPTURE  OF  THE  UTERUS.  423 

of  the  uterine  walls.  These  are  far  too  indefinite  to  be  relied  on, 
and  it  is  certain  that  the  rupture  generally  takes  place  without  any 
symptoms  that  would  have  afforded  reasonable  grounds  for  suspicion. 

General  Symptoms. — The  symptoms  are  often  so  distinct  and  alarm- 
ing as  to  leave  no  doubt  as  to  the  nature  of  the  case ;  not  unfrequently, 
however,  especially  if  the  laceration  be  partial,  they  are  by  no  means 
so  well  marked,  and  the  practitioner  may  be  uncertain  as  to  what  has 
taken  place.  In  the  former  class  of  cases  a  sudden  excruciating  pain 
is  experienced  in  the  abdomen,  generally  during  the  uterine  contrac- 
tions, accompanied  by  a  feeling,  on  the  part  of  the  patient,  of  some- 
thing having  given  way.  In  some  cases  this  has  been  accompanied 
by  an  audible  sound,  which  has  been  noticed  by  the  bystanders.  At 
the  same  time  there  is  generally  a  considerable  escape  of  blood  from 
the  vagina,  and  a  prominent  symptom  is  the  sudden  cessation  of  the 
previously  strong  pains;  Alarming  general  symptoms  soon  develop, 
partly  due  to  shock,  partly  to  loss  of  blood,  both  external  and  internal. 
The  face  exhibits  the  greatest  suffering,  the  skin  becomes  deadly  cold 
and  covered  with  a  clammy  sweat,  and  fainting,  collapse,  rapid  feeble 
pulse,  hurried  breathing,  vomiting,  and  all  the  usual  signs  of  extreme 
exhaustion  quickly  follow. 

Results  of  Abdominal  and  Vayinal  Examinations. — Abdominal  pal- 
pation and  vaginal  examination  both  afford  characteristic  indications 
in  well-marked  cases.  If  the  child,  as  often  happens,  have  escaped 
entirely,  or  in  great  part,  into  the  abdominal  cavity,  it  may  be  readily 
felt  through  the  abdominal  walls;  while,  in  the  former  case,  the  par- 
tially contracted  uterus  may  be  found  separate  from  it  in  the  form 
of  a  globular  tumor,  resembling  the  uterus  after  delivery.  Per 
vaginam  it  may  generally  be  ascertained  that  the  presenting  part  has 
suddenly  receded,  and  can  no  longer  be  made  out;  or  some  other 
part  of  the  foetus  may  be  found  in  its  place.  If  the  rupture  be  ex- 
tensive, it  may  be  appreciable  on  vaginal  examination,  and,  some- 
times, a  loop  of  intestine  may  be  found  protruding  through  the  tear. 
Other  occasional  signs  have  been  recorded,  such  as  an  emphysema- 
tous  state  of  the  lower  part  of  the  abdomen,  resulting  from  the 
entrance  of  air  into  the  cellular  tissue ;  or  the  formation  of  a  san- 
guineous tumor  in  the  hypogastriurn,  or  vagina.  These  are  too 
uncommon,  and  too  vague,  to  be  of  much  diagnostic  value. 

Symptoms  are  sometimes  Obscure. — Unfortunately  the  symptoms 
are  by  no  means  always  so  distinct,  and  cases  occur  in  which  most 
of  the  reliable  indications,  such  as  the  sudden  cessation  of  the  pains, 
the  external  hemorrhage,  and  the  retrocession  of  the  presenting  part, 
may  be  absent.  In  some  cases,  indeed,  the  symptoms  have  been  so 
obscure  that  the  real  nature  of  the  case  has  only  been  detected  after 
death.  It  is  rarely,  however,  that  the  occurrence  of  shock  and  pros- 
tration is  not  sufficiently  distinct  to  arouse  suspicion,  even  in  the 
absence  of  the  usual  marked  signs.  In  not  a  few  cases  distinct  and 
regular  contractions  have  gone  on  after  laceration,  and  the  child  has 
even  been  born  in  the  usual  way.  Of  course,  in  such  a  case,  mistake 
is  very  possible.  So  curious  a  circumstance  is  difficult  of  explana- 
tion. The  most  probable  way  of  accounting  for  it  is,  that  the  lacera- 


424  LABOR. 

tion  lias  not  implicated  the  fundus  of  the  uterus,  which  contracted 
sufficiently  energetically  to  expel  the  foetus.  Hence  it  will  be  seen 
that  the  symptoms  are  occasionally  obscure,  and  the  practitioner 
must  be  careful  not  to  overlook  the  occurrence  of  so  serious  an 
accident,  because  of  the  absence  of  the  usual  and  characteristic 
symptoms. 

Prognosis. — The  prognosis  is  necessarily  of  the  gravest  possible 
character,  but  modern  views  as  to  treatment  perhaps  justify  us  in 
saying  that  it  is  not  so  absolutely  hopeless  as  has  been  generally 
taught  in  our  obstetric  works.  When  we  reflect  on  what  has  oc- 
curred— the  profound  nervous  shock ;  the  profuse  hemorrhage,  both 
external,  and  especially  into  the  peritoneal  cavity,  where  the  blood 
coagulates  and  forms  a  foreign  body ;  the  passage  of  the  uterine 
contents  into  the  abdomen,  with  the  inevitable  result  of  inflamma- 
tion and  its  consequences,  if  the  patient  survive  the  primary  shock ; 
— the  enormous  fatality  need  cause  no  surprise.  Jolly  has  found  that 
out  of  580  cases  100  recovered,  that  is  in  the  proportion  of  1  out  of 
6.  This  is  a  far  more  favorable  result  than  we  are  generally  led  to 
anticipate  ;  and  as  many  of  the  recoveries  happened  in  apparently 
the  most  desperate  and  unfavorable  cases,  we  should  learn  the 
lesson  that  we  need  not  abandon  all  hope,  and  should  at  least  en- 
deavor to  rescue  the  patient  from  the  terrible  dangers  to  which  she 
is  exposed. 

As  regards  the  child  the  prognosis  is  almost  necessarily  fatal ;  and 
indeed,  the  cessation  of  the  foetal  heart-sounds  has  been  pointed  out 
by  McClintock  as  a  sign  of  rupture  in  doubtful  cases.  The  shock, 
the  profuse  hemorrhage,  and  the  time  that  must  necessarily  elapse 
before  the  delivery  of  the  child,  are  of  themselves  quite  sufficient  to 
explain  the  fact  that  the  foetus  is  almost  always  dead. 

Treatment. — From  what  has  been  said  of  the  impossibility  of  fore- 
telling the  occurrence  of  rupture,  it  must  follow  that  no  reliable  pro- 
phylactic treatment  can  be  adopted,  beyond  that  which  is  a  matter 
of  general  obstetric  principle,  viz.,  timely  interference  when  the 
uterine  contractions  seem  incapable  of  overcoming  an  obstacle  to  de- 
livery, either  on  the  part  of  the  pelvis  or  foetus. 

Indications  after  Rupture  has  taken  place. — After  rupture  the  main 
indications  are  to  effect  the  removal  of  the  child  and  the  placenta, 
to  rally  the  patient  from  the  effects  of  the  shock,  and,  if  she  survives 
so  long,  to  combat  the  subsequent  inflammation  and  its  consequences. 
By  far  the  most  important  point  to  decide  is  the  best  means  to  be 
adopted  for  the  removal  of  the  child ;  for  it  is  admitted  by  all  that 
the  hopeless  expectancy  that  was  recommended  by  the  older  accou- 
cheurs, or,  in  other  words,  allowing  the  patient  to  die  without  making 
any  effort  to  save  her,  is  quite  inadmissible.  If  the  foetus  be  entirely 
within  the  uterine  cavity,  no  doubt  the  proper  course  to  pursue  is  to 
deliver  at  once  per  vias  naturales,  either  by  turning,  by  forceps,  or 
by  cephalotripsy.  If  any  part  other  than  the  head  present,  turning 
will  be  best,  great  care  being  taken  to  avoid  further  increase  of  the 
laceration.  If  the  head  be  in  the  cavity  or  at  the  brim  of  the  pelvis, 
and  within  easy  reach  of  the  forceps,  it  may  be  cautiously  applied, 


RUPTURE  OF  THE  UTERUS.  425 

the  child  being  steadied  by  abdominal  pressure,  so  as  to  facilitate  its 
application.  If  there  be,  as  is  so  often  the  case,  some  slight  amount 
of  pelvic  contraction,  it  may  be  preferable  to  perforate  and  apply  the 
cephalotribe,  so  as  to  avoid  any  forcible  attempts  at  extraction,  which 
might  unduly  exhaust  the  already  prostrate  patient,  and  turn  the 
scale  against  her.  This  will  be  the  more  allowable  since  the  child 
is,  as  AVC  have  seen,  almost  always  dead,  and  we  might  readily  ascer- 
tain if  it  be  so  by  auscultation. 

Removal  of  the  Placenta. — -After  delivery  extreme  care  must  be 
taken  in  removing  the  placenta,  and  for  this  it  will  be  necessary  to 
introduce  the  hand.  The  placenta  will  generally  be  in  the  uterus, 
for  if  the  rent  be  not  large  enough  for  the  child  to  pass  through,  it 
may  be  inferred  that  the  placenta  will  not  have  done  so  either.  If 
it  has  escaped  from  the  uterus,  very  gentle  traction  on  the  cord  may 
bring  it  within  reach  of  the  hand,  and  so  the  passage  of  the  hand 
through  the  tear  to  search  for  it  will  be  avoided. 

Treatment  ichen  the  Fcetus  has  Escaped  out  of  the  Uterus. — There 
can  be  but  little  doubt  that,  in  the  cases  indicated,  such  is  the  proper 
treatment,  and  that  which  affords  the  mother  the  best  chance.  Un- 
fortunately, the  cases  in  which  the  child  remains  entirely  in  utero 
are  comparatively  uncommon,  and  generally  it  will  have  escaped 
into  the  abdomen,  along  with  much  extravasated  blood.  The  usual 
plan  of  treatment  recommended,  under  such  circumstances,  is  to  pass 
the  hand  through  the  fissure  (some  have  even  recommended  that  it 
should  be  enlarged  by  incision  if  necessary),  to  seize  the  feet  of  the 
foetus,  to  drag  it  back  through  the  torn  uterus,  and  then  to  reintro- 
duce  the  hand  to  search  for  and  remove  the  placenta.  Imagine  what 
occurs  during  the  process.  The  hand  gropes  blindly  among  the  ab- 
dominal viscera,  the  forcible  dragging  back  of  the  foetus  necessarily 
tears  the  uterus  more  and  more,  and,  above  all,  the  extravasated 
blood  remains  as  a  foreign  body  in  the  peritoneal  cavity,  and  neces- 
sarily gives  rise  to  the  most  serious  consequences.  It  is  surely  hardly 
a  matter  of  surprise  that  there  is  scarcely  a  single  case  on  record  of 
recovery  after  this  procedure. 

Reasons  favoring  Gastrotomy. — Of  late  years  a  strong  feeling  has 
existed  that,  whenever  the  child  has  entirely,  or  in  great  part,  escaped 
into  the  abdominal  cavity,  the  operation  of  gastrotomy  affords  the 
mother  a  far  better  chance  of  recovery ;  and  it  has  now  been  per- 
formed in  many  cases  with  the  most  encouraging  results.  It  is  easy 
to  see  why  the  prospects  of  success  are  greater.  The  uterus  being 
already  torn,  and  the  peritoneum  opened,  the  only  additional  danger 
is  the  incision  of  the  abdominal  parietes,  which  gives  us  the  oppor- 
tunity of  sponging  out  the  peritoneal  cavity,  as  in  ovariotomv,  and 
of  removing  all  the  extravasated  blood,  the  retention  of  which  so 
seriously  adds  to  the  dangers  of  the  case.  Another  advantage  is 
that,  if  the  patient  be  excessively  prostrate,  the  operation  may  be 
delayed  until  she  has  somewhat  rallied  from  the  effects  of  the  shock, 
whereas  delivery  by  the  feet  is  generally  resorted  to  as  soon  as  the 
rupture  is  recognized,  and  when  the  patient  is  in  the  worst  possible 
condition  for  interference  of  any  kind. 
28 


426 


LABOR. 


Comparative  Results  of  Various  Methods  of  Treatment. — Jolly  has 
carefully  tabulated  the  results  of  the  various  methods  of  treatment, 
and,  making  every  allowance  for  the  unavoidable  errors  of  statistics, 
it  seems  beyond  all  question  that  the  results  of  gastrotomy  are  so 
greatly  superior  to  those  of  other  plans,  that  I  think  its  adoption 
may  fairly  be  laid  down  as  a  rule  whenever  the  foetus  is  no  longer 
within  the  uterine  cavity. 

COMPARATIVE  RESULTS  OF  VARIOUS  METHODS  OF  TREATMENT  AFTER 
RUPTURE  OF  UTERUS. 


Treatment. 

Xo.  of  cases. 

Deaths. 

Recoveries. 

Per  cent,  of 
recoveries. 

Expectation         .... 

144 

142 

2 

1.45 

Extraction  per  vias  naturales 

382 

310 

72 

19 

Gastrotomy           .... 

38 

12 

26 

68.4 

Of  course  this  table  will  not  justify  the  conclusion  that  68  per 
cent,  of  the  cases  of  ruptured  uterus  in  which  gastrotomy  is  per- 
formed will  recover ;  but  it  may  fairly  be  taken  as  proving  that  the 
chances  of  recovery  are  at  least  three  or  four  times  as  great  as  when 
the  more  usual  practice  is  adopted. 

[According  to  Dr.  Trask's  reports,1  27  recovered,  out  of  115  that 
were  undelivered,  and  77  out  of  207,  delivered :  29  operations  by 
laparotomy  saved  22  women.  We  have  been  at  considerable  pains 
to  find  out  what  has  been  the  result  of  this  operation  in  the  United 
States,  and  thus  far  have  collected  30  cases,  with  a  saving  of  21 
women  and  1  child.  The  child  saved  resulted  from  an  immediate 
operation  with  a  pocket-knife,  performed  by  Dr.  Tupper,  of  Bay 
City,  Michigan,  in  1869 :  the  woman  recovered.  We  are  disposed 
to  believe  that  a  general  record  of  cases,  published  and  unpublished, 
would  show  a  saving  of  from  60  to  65  per  cent,  of  the  women,  which 
is  lower  than  that  claimed  by  Trask  and  Jolly,  collected  from  pub- 
lished reports.  We,  however,  believe  that  care  and  promptness  ought 
to  save  75  per  cent,  of  the  women,  and  more  than  the  percentage  of 
children  on  record. — ED.] 

Necessity  of  Care  in  Performing  the  Operation. — It  is  perhaps  need- 
less to  say  that  the  operation  must  be  performed  with  the  same 
minute  care  that  has  raised  ovariotomy  to  its  present  pitch  of  per- 
fection, and  that  especial  attention  should  be  paid  to  the  sponging 
out  of  the  peritoneum,  and  the  removal  of  foreign  matters. 

Recapitulation. — To  recapitulate,  I  think  what  has  been  said  jus- 
tifies the  following  rules  of  treatment  after  rupture: — 

1.  If  the  head  or  presenting  part  be  above  the  brim,  and  the  foetus 
still  in  utero — forceps,  turning,  or  cephalotripsy,  according  to  circum- 
stances. 

2.  If  the  head  be  in  the  pelvic  cavity — forceps  or  cephalotripsy. 

['  Am.  Journ.  Med.  Sci.,  vol.  xv.  N.  S.  1848,  pp.  104,  383 ;  vol.  xxxii.  p.  81.] 


RUPTURE  OF  THE  UTERUS.  427 

3.  If  the  foetus  have  wholly,  or  in  great  part,  escaped  into  the 
abdominal  cavity — gastrotomy. 

Subsequent  Treatment. — As  to  the  subsequent  treatment  little  need 
be  said,  since  in  this  we  must  be  guided  by  general  principles.  The 
chief  indication  will  be  to  remove  shock  and  rally  the  patient  by 
stimulants,  etc.,  and  to  combat  secondary  results  by  opiates  and  other 
appropriate  remedies. 

Lacerations  of  the  vagina  occasionally  take  place,  and  in  the  great 
majority  of  cases,  they  are  produced  by  instruments,  either  from  a 
want  of  care  in  their  introduction,  or  from  undue  stretching  of  the 
vaginal  walls  during  extraction  with  the  forceps.  Slight  vaginal 
lacerations  are  probably  much  more  common  after  forceps  delivery 
than  is  generally  believed  to  be  the  case.  As  a  rule  they  are  pro- 
ductive of  no  permanent  injury,  although  it  must  not  be  forgotten 
that  every  breach  of  continuity  increases  the  risk  of  subsequent 
septic  absorption.  When  the  laceration  is  sufficiently  deep  to  tear 
through  the  recto-vaginal  septum,  or  the  anterior  vaginal  wall,  the 
passage  of  the  urine  or  feces  is  apt  to  prevent  its  edges  uniting;  then 
that  most  distressing  condition,  recto-vaginal,  or  vesico- vaginal  fistula 
is  established. 

Itfmust  not  be  supposed  that  fistulse  are  often  the  result  of  injury 
during  operative  interference.  That  is  a  common  but  very  erroneous 
opinion  both  among  the  profession  and  the  public.  In  the  vast 
majority  of  cases  the  fistulous  opening  is  the  consequence  of  a  slough 
resulting  from  inflammation,  produced  by  long-continued  pressure  of 
the  vaginal  walls  between  the  child's  head  and  the  bony  pelvis,  in 
cases  in  which  the  second  stage  has  been  allowed  to  go  on  too  long. 
In  most  of  these  cases  instruments  were  doubtless  eventually  used, 
and  they  get  the  blame  of  the  accident;  whereas  the  fault  lay,  not 
in  their  being  employed,  but  rather  in  their  not  having  been  used 
soon  enough  to  prevent  the  contusion  and  inflammation  which  ended 
in  sloughing. 

When  vesico-vaginal  fistulae  are  the  result  of  lacerations  during 
labor,  the  urine  must  escape  at  once,  but  this  is  rarely  the  case.  In 
the  large  majority  of  cases  the  urine  does  not  pass  per  vaginam  until 
more  than  a  week  after  delivery,  showing  that  a  lapse  of  time  is. 
necessary  for  inflammatory  action  to  lead  to  sloughing.  In  order  to 
throw  some  light  on  these  points,  on  which  very  erroneous  views 
have  been  held,  I  have  carefully  examined  the  histories,  from  various 
sources,  of  63  cases  of  vesico-vaginal  fistula. 

1st.  In  20  no  instruments  were  employed.     Of  these,  there  were 

in  labor  under  24  hours       .....         2 

from  24-  to  48  hours  81 

u     48  to  70      "  .         .         .         2 

"     70  to  80      "          .         .         .        7 

"     80  hours  and  upwards  .         .         1 

20 

1  But  of  these  in  7  no  precise  time  is  stated.  6  of  them  are  marked  very  tedious, 
therefore  they  probably  exceeded  the  limit. 


428  LABOR. 

Therefore  out  of  these  20  cases  one-half  were  certainly  more  than 
48  hours  in  labor,  and  6  of  the  remaining  10  were  probably  so  also. 
In  only  1  of  them  is  the  urine  stated  to  have  escaped  per  vaginam 
immediately  after  delivery.  In  7  it  is  said  to  have  done  so  within 
a  week,  and  in  the  remainder  after  the  seventh  day. 

2d.  In  34  cases  instruments  were  used,  but  there  is  no  evidence  of 
their  having  produced  the  accident.  Of  these,  there  were  in  labor 

under  24  hours 2 

from  24  to  48  hours     ...  8 

"     48  to  72      "         .         .         .         10 
"     72  hours  and  upwards          .         14 

34 

The  urine  escaped  within  24  hours  in  2  cases  only,  within  a  week  in 
16,  and  after  the  seventh  day  in  15. 

So  that  here  again  we  have  the  history  of  unduly  protracted 
delivery,  24  out  of  the  34  having  been  certainly  more  than  48  hours 
in  labor. 

3d.  In  9  cases  the  histories  show  that  the  production  of  the  fistula 
may  fairly  be  ascribed  to  the  unskilled  use  of  instruments.    Of  tUese, 
there  were  in  labor  under  24  hours     ...         7 
from  24  to  48  hours       ...         1 
"     48  to  72      "  .         .         .         1 

9 

The  urine  escaped  at  once  in  7  cases,  and  in  the  remaining  2  after 
the  seventh  day. 

These  statistics  seem  to  me  to  prove,  in  the  clearest  manner,  that, 
in  the  large  majority  of  cases,  this  unhappy  accident  may  be  directly 
traced  to  the  bad  practice  of  allowing  labor  to  drag  on  many  hours 
in  the  second  stage  without  assistance,  and  not  to  premature  instru- 
mental interference. 

Treatment. — As  to  the  treatment  of  vaginal  laceration  little  can 
be  said.  In  the  slighter  cases  vaginal  injections  of  diluted  Condy's 
fluid  will  be  useful  to  lessen  the  risk  of  septic  absorption ;  and  the 
graver,  when  vesico- vaginal  or  recto-vaginal  fistulae  have  actually 
formed,  are  not  within  the  domain  of  the  obstetrician,  but  must  be 
treated  surgically  at  some  future  date. 


INVERSION    OF    THE    UTERUS.  429 


CHAPTER  XVII. 

INVERSION  OF  THE  UTERUS. 

INVERSION  of  the  uterus  shortly  after  the  birth  of  the  child  is  one 
of  the  most  formidable  accidents  of  parturition,  leading  to  symptoms 
of  the  greatest  urgency,  not  rarely  proving  fatal,  and  requiring  prompt 
and  skilful  treatment.  Hence  it  has  obtained  an  unusual  amount  of 
attention,  and  there  are  few  obstetric  subjects  which  have  been  more 
carefully  studied. 

An  Accident  of  Great  Rarity. — Fortunately,  the  accident  is  of  great 
rarity.  It  was  only  observed  once  in  upwards  of  190,800  deliveries 
at  the  Kotunda  Hospital  since  its  foundation  in  1745 ;  and  many 
practitioners  have  conducted  large  midwifery  practices  for  a  lifetime 
without  ever  having  witnessed  a  case.  It  is  none  the  less  needful, 
however,  that  we  should  be  thoroughly  acquainted  with  its  natural 
history,  and  with  the  best  means  of  dealing  with  the  emergency  when 
it  arises. 

Division  into  Acute  and  Chronic  Forms. — Inversion  of  the  uterus 
may  be  met  with  in  the  aciite  or  chronic  form ;  that  is  to  say,  it  may 
come  under  observation  either  immediately  or  shortly  after  its  occur- 
rence, or  not  until  after  a  considerable  lapse  of  time,  when  the  invo- 
lution following  pregnancy  has  been  completed.  The  latter  falls 
more  properly  under  the  province  of  the  gynaecologist,  and  involves 
the  consideration  of  many  points  that  would  be  out  of  place  in  a 
work  on  obstetrics.  Here,  therefore,  the  acute  form  alone  is  con- 
sidered. 

Description  of  Inversion. — Inversion  consists  essentially  in  the  en- 
larged and  empty  uterus  being  turned  inside  out,  either  partially  or 
entirely ;  and  this  may  occur  in  various  degrees,  three  of  which  are 
usually  described,  and  are  practically  useful  to  bear  in  mind.  In 
the  first  and  slightest  degree  there  is  merely  a  cup-shaped  depression 
of  the  fundus  (Fig.  139) ;  in  the  second  the  depression  is  greater,  so 
that  the  inverted  portion  forms  an  introsusception,  as  it  were,  and 
projects  downwards  through  the  os  in  the  form  of  a  round  ball,  not 
unlike  the  body  of  a  polypus,  for  which,  indeed,  a  careless  observer 
might  mistake  it;  and,  thirdly,  there  is  the  complete  variety,  in 
which  the  whole  organ  is  turned  inside  out  and  may  even  project 
beyond  the  vulva. 

Its  Symptoms. — The  symptoms  are  generally  very  characteristic, 
although,  when  the  amount  of  inversion  is  small,  they  may  entirely 
escape  observation.  They  are  chiefly  those  of  profound  nervous 
shock,  viz.,  fainting,  small,  rapid,  and  feeble  pulse,  possibly  convul- 
sions and  vomiting,  and  a  cold,  clammy  skin.  Occasionally  severe 
abdominal  pain,  and  cramp  and  bearing  down  are  felt.  Hemorrhage 


430 


LABOR. 


Partial  Inversion  of  the  Fnndus. 
(From  a  preparation  in  the  museum  of 
Guy's  Hospital.) 


FIG.  139.  is   a  frequent    accompaniment,    some- 

times to  a  very  alarming  extent,  espe- 
cially if  the  placenta  be  partially  or 
entirely  detached.  The  loss  of  blood 
depends  to  a  great  extent  on  the  con- 
dition of  the  uterine  parietes.  If  there 
be  much  contraction  of  the  part  that  is 
not  inverted,  the  introsuscepted  part 
may  be  sufficiently  compressed  to  pre- 
vent any  great  loss.  If  the  entire  organ 
be  in  a  state  of  relaxation,  the  loss  may 
be  excessive. 

Results  of  Physical  Examination. — 
The  occurrence  of  such  symptoms 
shortly  after  delivery  would  of  neces- 
sity lead  to  an  accurate  examination, 
when  the  nature  of  the  case  may  be  at 
once  ascertained.  On  passing  the  finger 
into  the  vagina,  we  either  find  the  entire 
uterus  forming  a  globular  mass,  to 
which  the  placenta  is  often  attached ; 
or,  if  the  inversion  be  incomplete,  the 
vagina  is  occupied  by  a  firm,  round, 
and  tender  swelling,  which  can  be  traced  upwards  through  the 
os  uteri.  The  hand  placed  on  the  abdomen  will  detect  the  absence 
of  the  round  ball  of  the  contracted  uterus,  and  bi-manual  examina- 
tion may  even  enable  us  to  feel  the  cup-shaped  depression  at  the 
site  of  inversion. 

Differential  Diagnosis. — When  such  signs  are  observed  immedi- 
ately after  delivery,  mistake  is  hardly  possible.  Numerous  instances, 
however,  are  recorded  in  which  the  existence  of  inversion  was  not 
immediately  detected,  and  the  tumor  formed  by  it  only  observed 
after  the  lapse  of  several  days,  or  even  longer,  when  the  general 
symptoms  led  to  vaginal  examination.  It  is  probable  that,  in  such 
cases,  a  partial  inversion  had  taken  place  shortly  after  delivery, 
which,  as  time  elapsed,  became  gradually  converted  into  the  more 
complete  variety.  In  a  case  of  this  kind,  as  in  a  chronic  inversion, 
some  care  is  necessary  to  distinguish  the  inversion  from  a  uterine 
polypus,  which  it  closely  resembles.  The  cautious  insertion  of  the 
sound  will  render  the  diagnosis  certain,  since  its  passage  is  soon  ar- 
rested in  inversion,  while,  if  the  tumor  be  polypoid,  it  readily  passes 
in  as  far  as  the  fundus. 

Manner  in  which  Inversion  is  Produced. — The  mechanism  by  which 
inversion  is  produced  is  well  worthy  of  study,  and  has  given  rise  to 
much  difference  of  opinion. 

Occasionally  produced  by  Accidental  Mechanical  Causes. — A  very 
general  theory  is,  that  it  is  caused,  in  many  cases,  by  mismanage- 
ment of  the  third  stage  of  labor,  either  by  traction  on  the  cord,  the 
placenta  being  still  adherent,  or  by  improperly  applied  pressure  on 
the  fundus ;  the  result  of  both  these  errors  being  a  cup-shaped  de- 


INVERSION  OF  THE  UTERUS.  431 

pression  of  the  fundus,  which  is  subsequently  converted  into  a  more 
complete  variety  of  inversion.  That  such  causes  may  suffice  to  start 
the  inversion  cannot  be  doubted,  but  it  is  probable  that  their  fre- 
quency has  been  much  exaggerated.  Still  there  are  numerous  re- 
corded cases  in  which  the  commencement  of  the  inversion  can  be 
traced  to  them.  Improperly  applied  pressure  (as  when  the  whole 
body  of  the  uterus  is  not  grasped  in  the  hollow  of  the  hand,  but 
when  a  monthly  nurse,  or  other  uninstructed  person,  presses  on  the 
lower  part  of  the  abdomen,  so  as  simply  to  push  down  the  uterus  en 
masse)  is  often  mentioned  in  histories  of  the  accident.  Thus  in  the 
"Edinburgh  Medical  Journal"  for  June,  1848,  a  case  is  related  in 
which  the  patient  would  not  have  a  medical  man,  but  was  attended 
by  a  midwife,  who,  after  the  birth  of  the  child,  pulled  on  the  cord, 
while  the  patient  herself  clasped  her  hands  and  pushed  down  her 
abdomen,  at  the  same  time  straining  forcibly,  when  the  uterus  be- 
came inverted,  and  the  patient  died  of  hemorrhage  before  assistance 
could  be  procured.  Here  both  the  mechanical  causes  mentioned 
were  in  operation.  In  several  cases  it  is  mentioned  that  the  accident 
occurred  while  the  nurse  was  compressing  the  abdomen.  That  the 
accident  is  practically  impossible  when  firm  and  equable  contraction 
has  taken  place,  cannot  be  questioned.  Hence  it  is  of  paramount 
importance  that  the  practitioner  should  himself  carefully  attend  to 
the  conduct  of  the  third  stage  of  labor. 

Often  Occurs  Spontaneously. — In  a  large  proportion  of  cases  no 
mechanical  causes  can  be  traced,  and  the  occurrence  of  spontaneous 
inversion  must  be  admitted.  There  are  various  theories  held  as  to 
how  this  occurs.  Partial  and  irregular  contraction  of  the  uterus  is 
generally  admitted  to  be  an  important  factor  in  its  production:  but 
it  is  still  a  matter  of  dispute  whether  the  inversion  is  produced  mainly 
by  an  active  contraction  of  the  fundus  and  body  of  the  uterus,  the 
lower  portion  and  cervix  being  in  a  state  of  relaxation ;  or  whether 
the  precise  reverse  of  this  exists,  the  fundus  being  relaxed  and  in  a 
state  of  quasi-paralysis,  while  the  cervix  and  lower  portion  of  the 
uterus  are  irregularly  contracted.  The  former  is  the  view  main- 
tained by  Radford  and  Tyler  Smith,  while  the  latter  is  upheld  by 
Matthews  Duncan. 

Evidence  in  Favor  of  Duncan's  Theory. — There  are  good  clinical 
reasons  for  believing  that  Duncan's  view  more  nearly  corresponds 
with  the  true  facts  of  the  case ;  for,  if  the  fundus  and  body  of  the 
uterus  be  really  in  a  state  of  active  contraction,  while  the  cervix  is 
relaxed,  we  have,  as  Duncan  points  out,  the  very  condition  which  is 
normal  and  desirable  after  delivery,  and  that  which  we  do  our  best 
to  produce.  If,  however,  the  opposite  condition  exist,  and  the  fundus 
be  relaxed,  while  the  lower  portion  is  spasmodically  contracted,  a 
state  exists  closely  allied  to  the  so-called  hour-glass  contraction. 
Supposing  now  any  cause  produces  a  partial  depression  of  the  fundus, 
it  is  easy  to  understand  how  it  may  be  grasped  by  the  contracted 
portion,  and  carried  more  and  more  down,  in  the  manner  of  an  intro- 
susception,  until  complete  inversion  results.  That  such  partial  paraly- 
sis of  the  uterine  walls  often  exists,  especially  about  the  placental 


432 


LABOR. 


FlG.  140. 


site,  was  long  ago  pointed  out  by  Rokitansky,  and  other  pathologists. 
This  theory  supposes  the  original  partial  depression  and  relaxation 
of  the  fundus.  How  this  is  often  produced  by  mismanagement  of 
the  third  stage  has  already  been  pointed  out ;  but,  even  in  the  absence 
of  such  causes,  it  may  result  from  strong  bearing-down  efforts  on  the 
part  of  the  patient,  or,  as  Duncan  holds,  from  the  absence  of  the 
retentive  power  of  the  abdomen.  Indeed  the  incompatibility  of  an 
actively  contracted  state  of  the  fundus  with  the  partial  depression 
which  is  essential,  according  to  both  views,  for  the  production  of 
inversion,  is  the  strongest  argument  in  favor  of  Duncan's  theory. 

Taylor's  Theory. — A  totally  different  view  has  more  recently  been 
sustained  by  Dr.  Taylor,  of  New  York,  who  maintains  that  "  spon- 
taneous active  inversion  of  the  uterus  rests 
upon  prolonged  natural  and  energetic  ac- 
tion of  the  body  and  fundus;  the  cervix, 
the  lower  part,  yielding  first,  is  thus  rolled 
out,  or  everted,  or  doubled  up.  as  there  is 
no  obstruction  from  the  contractility  of  the 
cervix,  which  is  at  rest  or  functionally 
paralyzed ;  the  body  is  gradually,  some- 
times instantaneously,  forced  lower  and 
lower,  or  inverted."1  That  partial  inver- 
sion may  commence  at  the  cervix  was 
pointed  out  by  Duncan  in  his  paper,  who 
depicts  it  in  the  accompanying  diagram 
(Fig.  140),  and  states  it  to  be  of  not  unfre- 
quent  occurrence.  It  is  not  impossible  that 
occasionally  such  a  state  of  things  should 
be  carried  on  to  complete  inversion.  But 
there  are  serious  objections  to  the  accep- 
tance of  Dr.  Taylor's  view  that  such  is  the 
principal  cause  of  inversion,  since  the  pro- 
cess above  described  would  be  of  necessity 

a  slow  and  long-continued  one,  whereas  nothing  is  more  certain  than 
that  inversion  is  generally  sudden  and  accompanied  by  acute  symp- 
toms of  shock,  and  is  often  attended  by  severe  hemorrhage,  which 
could  not  occur  when  such  excessive  contraction  was  taking  place. 

Treatment. — The  treatment  of  inversion  consists  in  restoring  the 
organ  to  its  natural  condition  as  soon  as  possible.  Every  moment's 
delay  only  serves  to  render  restoration  more  difficult,  as  the  inverted 
portion  becomes  swollen  and  strangulated ;  whereas  if  the  attempt 
at  reposition  be  made  immediately,  there  is  generally  comparatively 
little  difficulty  in  effecting  it.  Therefore  it  is  of  the  utmost  import- 
ance that  no  time  should  be  lost,  and  that  we  should  not  overlook  a 
partial  or  incomplete  inversion.  Hence  the  occurrence  of  any  unu- 
sual shock,  pain,  or  hemorrhage  after  delivery,  without  any  readily 
ascertained  cause,  should  always  lead  to  a  careful  vaginal  examina- 
tion. A  want  of  attention  to  this  rule  has  too  often  resulted  in  the 


Illustrating  the  Commencement 
of  I  u  version  at  the  Ceryix.  (After 
Duncan). 


1  New  York  Med.  Journ.,  1872. 


INVERSION    OF    THE    UTERUS.  433 

existence  of  partial  inversion  being  overlooked,  until  its  reduction 
was  found  to  be  difficult  or  impossible. 

Mode  of  Attempting  Reduction. — In  attempting  to  reduce  a  recent 
inversion,  the  inverted  portion  of  the  uterus  should  be  grasped  in 
the  hollow  of  the  hand  and  pushed  gently  and  firmly  upwards  into 
its  natural  position,  great  care  being  taken  to  apply  the  pressure  in 
the  proper  axis  of  the  pelvis,  and  to  use  counter-pressure,  by  the 
left  hand,  on  the  abdominal  Avails.  Barnes  lays  stress  on  the  import- 
ance of  directing  the  pressure  towards  one  side,  so  as  to  avoid  the 
promontory  of  the  sacrum.  The  common  plan  of  endeavoring  to 
push  back  the  fundus  first  has  been  well  shown  by  McClintock1  to 
have  the  disadvantage  of  increasing  the  bulk  of  the  mass  that  has 
to  be  reduced,  and  he  advises  that,  while  the  fundus  is  lessened  in 
size  by  compression,  we  should,  at  the  same  time,  endeavor  to  push 
up  first  the  part  that  was  less  inverted,  that  is  to  say,  the  portion 
nearest  the  os  uteri.  Should  this  be  found  impossible,  some  assist- 
ance may  be  derived  from  the  manoeuvre,  recommended  by  Merriman 
and  others,  of  first  endeavoring  to  push  up  one  side  or  wall  of  the 
uterus,  and  then  the  other,  alternating  the  upward  pressure  from  one 
side  to  the  other  as  we  advance.  It  often  happens  as  the  hand  is 
thus  applied,  that  the  uterus  somewhat  suddenly  reinverts  itself, 
sometimes  with  an  audible  noise,  much  as  an  India-rubber  bottle 
would  do  under  similar  circumstances.  When  reposition  has  taken 
place  the  hand  should  be  kept  for  some  time  in  the  uterine  cavity  to 
excite  tonic  contraction;  or  Barnes's  suggestion  of  injecting  a  weak 
solution  of  perchloride  of  iron  may  be  adopted,  so  as  to  constrict  the 
uterine  walls,  and  prevent  a  recurrence  of  the  accident. 

It  is  hardly  necessary  to  point  out  how  much  these  manoeuvres 
will  be  facilitated  by  placing  the  patient  fully  under  the  influence  of 
an  anaesthetic. 

Management  of  the  Placenta. — There  has  been  much  difference  of 
opinion  as  to  the  management  of  the  placenta,  in  cases  in  which  it  is 
still  attached  when  inversion  occurs.  Should  we  remove  it  before 
attempting  reposition,  or  should  we  first  endeavor  to  reinvert  the 
organ,  and  subsequently  remove  the  placenta?  The  removal  of  the 
placenta  certainly  much  diminishes  the  bulk  of  the  inverted  portion, 
and,  therefore,  renders  reposition  easier.  On  the  other  hand,  if  there 
be  much  hemorrhage,  as  is  so  frequently  the  case,  the  removal  of  the 
placenta  may  materially  increase  the  loss  of  blood.  For  this  reason, 
most  authorities  recommend  that  an  endeavor  should  be  made  at 
reduction  before  peeling  off  the  after  birth.  But  if  any  delay  or 
difficulty  be  experienced  from  the  increased  bulk,  no  time  should  be 
lost,  and  it  is  in  every  way  better  to  remove  the  placenta  and  en- 
deavor to  reinvert  the  organ  as  soon  as  possible. 

Management  of  Cases  detected  some  time  after  Delivery. — Supposing 
we  meet  with  a  case  in  which  the  existence  of  inversion  has  been 
overlooked  for  days,  or  even  for  a  week  or  two,  the  same  procedure 
must  be  adopted ;  but  the  difficulties  are  much  greater,  and  the 

1  Diseases  of  Women,  p.  79. 


434  LABOR. 

longer  the  delay,  the  greater  they  are  likely  to  be.  Even  now, 
however,  a  well-conducted  attempt  at  taxis  is  likely  to  succeed. 
Should  it  fail,  we  must  endeavor  to  overcome  the  difficulty  by  con- 
tinuous pressure  applied  by  means  of  caoutchouc  bags,  distended 
with  water,  and  left  in  the  vagina.  It  is  rarely  that  this  will  fail  in 
a  comparatively  recent  case,  and  such  only  are  now  under  considera- 
tion. It  is  likely  that  by  pressure,  applied  in  this  way  for  twenty- 
four  or  forty-eight  hours,  and  then  followed  by  taxis,  any  case 
detected  before  the  involution  of  the  uterus  is  completed  may  be 
successfully  treated. 


PART    IV. 

OBSTETRIC  OPERATIONS. 


CHAPTER  I. 

INDUCTION   OF   PREMATURE   LABOR. 

THE  first  of  the  obstetric  operations  we  have  to  consider  is  the 
induction  of  premature  labor,  an  operation  which,  like  the  use  of  for- 
ceps, was  first  suggested  and  practised  in  this  country,  and  the  recog- 
nition of  which,  as  a  legitimate  procedure,  we  also  chiefly  owe  to  the 
labor  of  our  fellow-countrymen,  in  spite  of  much  opposition  both  at 
home  and  abroad.  It  is  not  known  with  certainty  to  whom  we  owe 
the  original  suggestion;  but  we  are  told  by  Denrnan  that  in  the  year 
1756  there  was  a  consultation  of  the  most  eminent  physicians  at  that 
time  in  London,  to  consider  the  advantages  w-hich  might  be  expected 
from  the  operation.  The  proposal  met  with  formal  approval,  and 
was  shortly  after  carried  into  practice  by  Dr.  Macaulay,  the  patient 
being  the  wife  of  a  linendraper  in  the  Strand.  From  that  time  it 
has  flourished  in  Great  Britain,  the  sphere  of  its  application  has  been 
largely  increased,  and  it  has  been  the  means  of  saving  many  mothers 
and  children,  who  would  otherwise,  in  all  probability,  have  perished. 
On  the  Continent,  it  was  long  before  the  operation  was  sanctioned  or 
practised.  Although  recommended  by  some  of  the  most  eminent 
German  practitioners,  it  was  not  actually  performed  until  the  year 
1804.  In  France  the  opposition  was  long-continued  and  bitter. 
Many  of  the  leading  teachers  strongly  denounced  it,  and  the  Academy 
of  Medicine  formally  discountenanced  it  so  late  as  the  year  1827. 
The  objections  were  chiefly  based  on  religious  grounds,  but  partly, 
no  doubt,  on  mistaken  notions  as  to  the  object  proposed  to  be  gained. 
Although  frequently  discussed,  the  operation  was  never  actually  car- 
ried into  practice  until  the  year  1831,  when  Stoltz  performed  it  with 
success.  Since  that  time  opposition  has  greatly  ceased,  and  it  is  now 
employed  and  highly  recommended  by  the  most  distinguished  ob- 
stetricians of  the  French  schools. 

Objects  of  the  Operation. — In  inducing  premature  labor,  we  propose 
to  avoid  or  lessen  the  risk  to  which,  in  certain  cases,  the  mother  is 
exposed  by  delivery  at  term,  or  to  save  the  life  of  the  child  which 
might  otherwise  be  endangered.  Hence  the  operation  may  be  indi- 
cated either  on  account  of  the  mother  alone,  or  of  the  child  alone,  or, 
as  not  ^infrequently  happens,  of  both  together. 


436  OBSTETRIC  OPERATIONS. 

Defective  Proportion  betiveen  the  Child  and  Pelvis  is  the  most  Fre- 
quent Indication. — In  by  far  the  largest  number  of  cases  the  operation 
is  performed  on  account  of  defective  proportion  between  the  child 
and  the  maternal  passages,  due  to  some  abnormal  condition  on  the 
part  of  the  mother.  This  want  of  proportion  may  depend  on  the 
presence  of  tumors  either  of  the  uterus  or  growing  from  the  pelvis. 
But  most  frequently  it  arises  from  deformity  of  the  pelvis  (p.  383), 
and  it  is  needless  to  repeat  what  has  been  said  on  that  point.  I 
shall,  therefore,  only  briefly  refer  to  a  few  more  uncommon  causes, 
which  occasionally  necessitate  its  performance. 

Habitually  Large  Size  of  the  Fcetal  Head. — One  of  these  is  an  habit- 
ually large,  or  over-firmly  ossified,  foetal  head.  Should  we  meet 
with  a  case  in  which  the  labors  are  always  extremely  difficult,  and 
the  head  apparently  of  unusual  size,  although  there  is  no  apparent 
want  of  space  in  the  pelvis,  the  induction  of  labor  would  be  perfectly 
justifiable,  and  in  all  probability  would  accomplish  the  desired  ob- 
ject. In  such  cases  the  full  period  of  delivery  would  require  to  be 
anticipated  by  a  very  short  time.  A  week  or  a  fortnight  might 
make  all  the  difference  between  a  labor  of  extreme  severity,  and  one 
of  comparative  ease. 

Condition  of  the  Mother's  Health  calling  for  the  Operation. — There 
is  a  large  class  of  cases  in  which  the  condition  of  the  mother  indi- 
cates the  operation.  Many  of  these  have  already  been  considered 
when  treating  of  the  diseases  of  pregnancy.  Amongst  them  may  be 
mentioned  vomiting  which  has  resisted  all  treatment,  and  which  has 
produced  a  state  of  exhaustion  threatening  to  prove  fatal ;  chorea, 
albuminuria,  convulsions,  or  mania ;  excessive  anasarca,  ascites,  or 
dyspnoea  connected  with  disease  of  the  heart,  lungs,  or  liver,  may  be, 
in  a  great  measure,  caused  by  the  pressure  of  the  enlarged  uterus ; 
in  fact,  any  condition  or  disease  affecting  the  mother,  provided  only 
we  are  convinced  that  the  termination  of  pregnancy  would  give  the 
patient  relief,  and  that  its  continuance  would  involve  serious  danger. 
It  need  hardly  be  pointed  out  that  the  induction  of  labor  for  any 
Such  causes  involves  grave  responsibility,  and  is  decidedly  open  to 
abuse;  no  practitioner  would,  therefore,  be  justified  in  resorting  to 
it,  especially  if  the  child  have  not  reached  a  viable  age,  without  the 
most  anxious  consideration.  No  general  rules  can  be  laid  down. 
Each  case  must  be  treated  on  its  own  merits.  It  is  obvious  that  the 
nearer  the  patient  is  to  the  full  period,  the  greater  will  be  the  chance 
of  the  child  surviving,  and  the  less  hesitation  need  then  be  felt  in 
consulting  the  interests  of  the  mother. 

Conditions  affecting  the  Safety  of  the  Child  alone. — In  another  class 
of  cases  the  operation  is  indicated  by  circumstances  affecting  the  life 
of  the  child  alone.  Of  these  the  most  common  are  those  in  which 
the  child  dies,  in  several  successive  pregnancies,  before  the  termina- 
tion of  utero-gestation.  This  is  generally  the  result  of  fatty,  calcare- 
ous, or  syphilitic  degeneration  of  the  placenta,  which  is  thus  rendered 
incapable  of  performing  its  functions.  These  changes  in  the  placenta 
seldom  commence  until  a  comparatively  advanced  period  of  preg- 
nancy; so  that  if  labor  be  somewhat  hastened,  we  may  hope  to 


INDUCTION    OF    PREMATURE    LABOR.  437 

enable  the  patient  to  give  birth  to  a  living  and  healthy  child.  The 
experience  of  the  mother  will  indicate  the  period  at  which  the  death 
of  the  foetus  has  formerly  taken  place,  as  she  would  then  have  appre- 
ciated a  difference  in  her  sensations,  a  diminution  in  the  vigor  of  the 
foetal  movements,  a  sense  of  weight  and  coldness,  and  similar  signs. 
For  some  weeks  before  the  time  at  which  this  change  has  been  expe- 
rienced, we  should  carefully  auscultate  the  foetal  heart  from  day  to 
day,  and,  in  most  cases,  the  approach  of  danger  Avill  be  indicated 
sufficiently  soon  to  enable  us  to  interfere  with  success,  by  tumultuous 
and  irregular  pulsations,  or  a  failure  in  their  strength  and  frequency. 
On  the  detection  of  these,  or  on  the  mother  feeling  that  the  move- 
ments of  the  child  are  becoming  less  strong,  the  operation  should  at 
once  be  performed.  Simpson  also  induced  premature  labor  with 
success  in  a  patient  who  twice  gave  birth  to  hydrocephalic  children. 
In  the  third  pregnancy,  which  he  terminated  before  the  natural 
period,  the  child  was  well-formed  and  healthy. 

Induction  of  Labor  -when  the  Mother  is  mortally  111. — Some  obstetri- 
cians have  proposed  to  induce  labor,  with  the  view  of  saving  the 
child,  when  the  mother  was  suffering  from  mortal  disease.  This 
indication  is,  however,  so  extremely  doubtful,  from  a  moral  point  of 
view,  that  it  can  hardly  be  considered  as  ever  justifiable. 

Various  Methods  of  Inducing  Labor ;  their  mode  of  Action. — The 
means  adopted  for  the  induction  of  labor  are  very  numerous.  Some 
of  them  act  through  the  maternal  circulation,  as  the  administration 
of  ergot,  and  other  oxytocics;  others  by  their  power  of  exciting  reflex 
action,  or  by  interfering  with  the  integrity  of  the  ovum,  or  by  a  com- 
bination of  both,  as  the  vaginal  douche  separation  of  the  membranes 
from  the  uterine  walls,  puncture  of  the  ovurn,  dilatation  of  the  os, 
stimulating  enemata,  or  irritation  of  the  breasts.  The  former  class 
are  never  employed  in  modern  obstetric  practice.  Of  the  latter,  some 
offer  special  advantages  in  particular  cases,  but  none  are  equally 
adapted  for  all  emergencies.  Often  a  combination  of  more  methods 
than  one  will  be  found  most  useful.  I  shall  mention  the  various 
methods  in  use,  and  discuss  briefly  the  relative  advantages  and  dis- 
advantages of  each. 

Puncture  of  Membranes. — The  evacuation  of  the  liquor  amnii,  by 
the  puncture  of  the  membranes,  was  the  first  method  practised,  and 
was  that  recommended  by  Denman  and  all  the  earlier  writers.  It  is 
the  most  certain  which  can  be  employed,  as  it  never  fails,  sooner  or 
later,  to  induce  uterine  contractions.  There  are,  however,  several 
disadvantages  connected  with  it,  which  are  sufficient  to  contra-indi- 
cate  its  use  in  the  majority  of  cases.  It  is  uncertain  as  regards  the 
time  taken  in  producing  the  desired  effect,  pains  sometimes  coming 
on  within  a  few  hours,  but  occasionally  not  until  several  days  have 
elapsed.  The  contracting  walls  of  the  uterus  press  directly  on  the 
body  of  the  child,  which,  being  frail  and  immature,  is  less  able  to 
bear  the  pressure  than  at  the  full  period  of  pregnancy.  Hence  it 
involves  great  risk  to  the  foetus.  Besides,  the  escape  of  the  water 
does  away  with  the  fluid  wedge  so  useful  in  dilating  the  os,  and 
should  version  be  necessary  from  mal-presentation — a  complication 


438  OBSTETRIC  OPERATIONS. 

more  likely  to  occur  than  in  natural  labor- — the  operation  would 
have  to  be  performed  under  very  unfavorable  conditions.  These 
objections  are  sufficient  to  justify  the  ordinary  opinion  that  this  pro- 
cedure should  not  be  adopted,  unless  other  means  had  been  tried  and 
failed.  Every  now  and  then  cases  are  met  with  in  \vhich  it  is  ex- 
tremely difficult  to  arouse  the  uterus  to  action,  and,  under  such 
circumstances,  in  spite  of  its  drawbacks,  this  method  will  be  found 
to  be  very  valuable.  When  the  operation  has  to  be  performed  before 
the  child  is  viable,  that  is,  before  the  seventh  month,  these  objections 
do  not  hold,  and  then  it  is  the  simplest  and  readiest  procedure  we 
can  adopt.  Indeed,  in  producing  early  abortion,  no  other  is  prac- 
ticable. The  operation  itself  is  most  simple,  requiring  only  a  quill, 
stiletted  catheter,  or  other  suitable  instrument,  to  be  passed  up  to 
the  os,  carefully  guarded  by  the  fingers  of  the  left  hand  previously 
introduced,  and  to  be  pressed  against  the  membranes  until  perfora- 
tion is  accomplished.  Meissner,  of  Leipsic,  has  proposed,  as  a  modi- 
fication of  this  plan,  that  the  membranes  should  be  punctured 
obliquely,  three  or  four  inches  above  the  os,  so  as  to  admit  of  a 
gradual  and  partial  escape  of  the  amniotic  fluid,  thus  lessening  the 
risk  to  the  child  from  pressure  by  the  uterus.  For  this  purpose  he 
employed  a  curved  silver  canula,  containing  a  small  trocar,  which 
can  be  projected  after  introduction.  The  risk  of  injuring  the  uterus 
by  such  an  instrument  would  be  considerable,  and  we  have  other 
and  better  means  at  our  command  which  render  it  unnecessary. 
When  we  require  to  produce  early  abortion,  it  would  be  well  not  to 
attempt  to  puncture  the  membranes  with  a  sharp-pointed  instrument. 
The  object  can  be  effected  with  equal  certainty,  and  greater  safety, 
by  passing  an  ordinary  uterine  sound  through  the  os,  and  turning  it 
round  once  or  twice. 

Administration  of  Oxytocics. — The  administration  of  ergot  of  rye, 
either  alone,  or  combined  with  borax  and  cinnamon,  has  been  some- 
times resorted  to.  This  practice  has  been  principally  advocated  by 
Eamsbotham,  who  was  in  the  habit  of  exhibiting  scruple  doses  of 
the  powdered  ergot  every  fourth  hour,  until  delivery  took  place. 
Sometimes  he  found  that  as  many  as  thirty  or  forty  doses  were  re- 
quired to  effect  the  object ;  occasionally  labor  commenced  after  a 
single  dose.  Finding  that  the  infantile  mortality  was  very  great 
when  this  method  was  followed,  he  modified  it,  and  administered 
two  or  three  doses  only,  and,  if  these  proved  insufficient,  he  punc- 
tured the  membranes.  There  can  be  no  doubt  that  ergot  possesses 
the  power  of  inducing  uterine  contractions.  The  risk  to  the  child 
is,  however,  quite  as  great  as  when  the  membranes  are  punctured ; 
for  not  only  is  it  subject  to  injurious  pressure  from  the  tumultuous 
and  irregular  contractions  which  the  ergot  produces,  but  the  drug 
itself,  when  given  in  large  doses,  seems  to  exert  a  poisonous  influence 
on  the  foetus.  For  these  reasons  ergot  may  properly  be  excluded 
from  the  available  means  of  inducing  labor. 

Methods  acting  Indirectly  on  the  Uterus. — Various  methods  have 
been  recommended  which  act  indirectly  on  the  uterus,  the  source  of 
irritation  being  at  a  distance.  Thus  D'Outrepont  used  frequently 


INDUCTION    OF    PREMATURE    LABOR.  439 

repeated  abdominal  frictions  and  tight  bandages.  Scanzoni,  remem- 
bering the  intimate  connection  between  the  mammae  and  uterus,  and 
the  tendency  which  irritation  of  the  former  has  to  induce  contraction 
of  the  latter,  recommended  the  frequent  application  of  cupping- 
glasses  to  the  breasts.  Had  ford  and  others  have  employed  galvanism. 
Stimulating  enemata  have  been  employed.  All  these  methods  have 
occasionally  proved  successful,  and,  unlike  the  former  plans  we  have 
mentioned,  they  are  not  attended  by  any  special  risk  to  the  child. 
Thev  are,  however,  much  too  uncertain  to  be  relied  on,  besides  being 
irksome  both  to  the  patient  and  practitioner. 

The  artificial  dilatation  of  the  os  uteri,  in  imitation  of  its  natural 
opening  in  labor,  was  first  practised  by  Kliige.  He  was  in  the  habit 
of  passing  within  the  os  a  tent  made  of  compressed  sponge,  and 
allowing  it  to  dilate  by  imbibition  of  fluid.  If  labor  were  not  pro- 
voked within  twenty-four  hours  he  removed  it,  and  introduced  one 
of  larger  dimensions,  changing  it  as  often  as  was  necessary  until  his 
object  was  accomplished.  Although  this  operation  seldom  failed  to 
induce  labor,  it  had  the  disadvantage  of  occupying  an  indefinite  time, 
and  the  irritation  produced  was  often  painful  and  annoying.  Dr. 
Keiller,  of  Edinburgh,  was  the  first  to  suggest  the  use  of  caoutchouc 
bags,  distended  by  air,  as  a  means  of  dilating  the  os.  This  plan  has 
been  perfected  by  Dr.  Barnes  in  his  well-known  dilators,  which  are 
of  great  use  in  many  cases  in  which  artificial  dilatation  of  the  cervix 
is  necessary.  They  consist  of  a  series  of  india-rubber  bags  of  various 
sizes,  with  a  tube  attached  (Fig.  141),  through  which 
water  can  be  injected  by  an  ordinary  Higginson's  FIG.  141. 
syringe.  They  have  a  small  pouch  fixed  externally, 
in  which  a  sound  can  be  placed,  so  as  to  facilitate 
their  introduction.  When  distended  with  water  the 
bags  assume  somewhat  of  a  fiddle  shape,  bulging  at 
both  extremities,  which  insures  their  being  retained 
within  the  os.  When  first  introduced  into  practice 
as  a  means  of  inducing  labor,  it  was  thought  that 
this  method  gave  a  complete  control  over  the  pro- 
cess, so  that  it  could  be  concluded  within  a  definite 
time  at  the  will  of  the  operator.  The  experience  of 
those  who  have  used  it  much  has  certainly  not  justi- 
fied this  anticipation.  It  is  true  that,  occasionally, 
contractions  supervene  within  a  few  hours  after  dila- 
tation has  been  commenced ;  but,  on  the  other  hand, 
the  uterus  often  responds  very  imperfectly  to  this 
kind  of  stimulus,  and  the  bags  may  be  inserted  for 
many  consecutive  hours  without  the  desired  result  supervening;  the 
puncture  of  the  membranes  being  eventually  necessary  in  order  to 
hasten  the  process.  Indeed,  my  own  experience  would  lead  me  to 
the  conclusion  that,  as  a  means  of  evoking  uterine  contraction,  cervi- 
cal dilatation  is  very  unsatisfactory.  Dr.  Barnes  himself  has  evi- 
dently seen  reason  to  modify  his  original  views,  for,  while  he  at  first 
talked  of  the  bags  as  enabling  us  to  induce  labor  with  certainty  at  a 
given  time,  he  has  since  recommended  that  uterine  action  should  be 


440  OBSTETRIC  OPERATIONS. 

first  provoked  by  other  means,  the  dilators  being  subsequently  used 
to  accelerate  the  labor  thus  brought  on.  The  bags  thus  employed 
find,  as  I  believe,  their  most  useful  and  a  very  valuable  application; 
but  when  used  in  this  way  they  cannot  be  considered  a  means  of 
originating  uterine  action.  A  subsidiary  objection  to  the  bags  is  the 
risk  of  displacing  the  presenting  part.  I  have,  for  example,  intro- 
duced them  when  the  head  was  presenting,  and,  on  their  removal, 
found  the  shoulder  lying  over  the  os.  It  is  not  difficult  to  understand 
how  the  continuous  pressure  of  a  distended  bag  in  the  internal  os 
might  easily  push  away  the  head,  which  is  so  readily  movable  as 
long  as  the  membranes  are  unruptured.  Still,  if  labor  be  in  progress, 
and  the  os  insufficiently  dilated,  the  possibility  of  this  occurrence  is 
not  a  sufficient  reason  for  not  availing  ourselves  of  the  undoubtedly 
valuable  assistance  which  the  dilators  are  capable  of  giving. 

Separation  of  the  Membranes. — Some  processes  for  inducing  labor 
act  directly  on  the  ovum,  by  separating  the  membranes,  to  a  greater 
or  less  extent,  from  the  uterine  walls.  The  first  procedure  of  the 
kind  was  recommended  by  Dr.  Hamilton,  of  Edinburgh,  and  con- 
sisted in  the  gradual  separation  of  the  membranes  for  one  or  two 
inches  all  round  the  lower  segment  of  the  uterus.  To  reach  them, 
the  finger  had  to  be  gently  insinuated  into  the  interior  of  the  os, 
which  was  gradually  dilated  to  a  sufficient  extent  by  a  series  of  suc- 
cessive operations,  repeated  at  intervals  of  three  or  four  hours. 
When  this  had  been  accomplished,  the  fore-finger  was  inserted  and 
swept  round  between  the  membranes  and  the  uterus,  but  it  was  fre- 
quently found  necessary  to  introduce  the  greater  part  of  the  hand  to 
effect  the  object,  and,  sometimes,  even  this  was  not  sufficient,  and  a 
female  catheter  or  other  instrument  had  to  be  used  for  the  purpose. 
The  method  was  generally  successful  in  bringing  on  labor,  but  it  now 
and  then  failed,  even  in  Dr.  Hamilton's  hands.  It  is  certainly  based 
on  correct  principles,  but  it  is  tedious  and  painful  both  to  the  prac- 
titioner and  the  patient,  and  very  uncertain  in  its  time  of  action. 
For  these  reasons  it  has  never  been  much  practised. 

Vaginal  and  Uterine  Douches. — In  the  year  1836  Kiwisch  suggested 
a  plan  wrhich,  from  its  simplicity,  has  met  with  much  approval.  It 
consists  in  projecting,  at  intervals,  a  stream  of  warm  or  cold  water 
against  the  os  uteri.  Its  action  is  doubtless  complex.  Kiwisch  him- 
self believed  that  relaxation  of  the  soft  parts,  through  the  imbibition 
of  water,  was  the  determining  cause  of  labor.  Simpson  found  that 
the  method  failed,  unless  the  water  mechanically  separated  the  mem- 
branes from  the  uterine  walls.  Besides  this  effect,  it  probably  di- 
rectly induces  reflex  action,  by  distending  the  vagina  and  dilating  the 
os.  In  using  it,  it  has  been  customary  to  administer  a  douche  twice 
daily,  and  more  frequently  if  rapid  effects  be  desired.  The  number 
required  varies  in  different  cases.  The  largest  number  Kiwisch 
found  it  necessary  to  use  was  17,  the  smallest  4.  The  average  time 
that  elapses  before  labor  sets  in  is  four  days.  Hence  the  method  is 
obviously  useless  when  rapid  delivery  is  required. 

Dr.  Cohen,  of  Hamburgh,  introduced  an  important  modification  of 
the  process,  which  has  been  considerably  practised.  It  consists  in 


INDUCTION    OF    PREMATURE    LABOR.  441 

passing  a  silver  or  gum-elastic  catheter  some  inches  within  the  os, 
between  the  membranes  and  the  uterine  walls,  and  injecting  the  fluid 
through  it  directly  into  the  cavity  of  the  uterus.  He  used  creosote, 
or  tar-water,  and  injected,  without  stopping,  until  the  patient  com- 
plained of  a  feeling  of  distension.  Others  have  found  the  plan 
equally  efficacious  when  they  only  employed  a  small  quantity  of 
plain  water,  such  as  7  or  8  ounces.  Professor  Lazarewitch,  of  Char- 
koff,  is  a  strong  advocate  of  this  method.  He  believes  that  uterine 
action  is  evoked  much  more  rapidly  and  certainly  if  the  water  be 
injected  near  the  fundus,  and  he  has  contrived  an  instrument  for  the 
purpose,  with  a  long  metallic  nozzle. 

Dangers  of  these  Plans. — So  many  fatal  cases  have  followed  these 
methods,  that  it  cannot  be  doubted  that,  in  spite  of  their  certainty 
and  simplicity,  there  is  an  element  of  risk  in  them  which  should  not 
be  overlooked.  Many  of  these  are  recorded  in  Barnes's  work,  and 
he  comes  to  the  conclusion,  which  the  facts  unquestionably  justify, 
that  "  the  douche,  whether  vaginal  or  intra-uterine,  ought  to  be  ab- 
solutely condemned  as  a  means  of  inducing  labor."  The  precise  rea- 
son of  the  danger  is  not  very  obvious.  Sudden  stretching  of  the 
uterine  walls,  producing  shock,  has  been  supposed  to  have  caused  it; 
but  in  many  of  the  fatal  cases  the  symptoms  have  been  rather  those 
attending  the  passage  of  air  into  the  veins,  and  it  is  easy  to  under- 
stand how  air  may  have  been  introduced,  in  this  way,  into  the  large 
uterine  sinuses. 

Injection  of  Carbonic  Acid  Gas. — Simpson  and  Scanzoni  have  both 
tried  with  success  the  injection  of  carbonic  acid  gas  into  the  vagina. 
Fatal  results  have,  however,  followed  its  employment,  and  Simpson 
has  expressed  an  opinion  that  the  experiment  should  not  be  re- 
peated. 

Simpson's  Method  of  Operating. — Simpson  originally  induced  labor 
by  passing  the  uterine  sound  within  the  os,  and  up  towards  the  fun- 
dus, and,  when  it  had  been  inserted  to  a  sufficient  extent,  moving  it. 
slightly  from  side  to  side.  He  was  led  to  adopt  this  procedure  in. 
the  belief  that  we  might  thus  closely  imitate  the  separation  of  the 
decidua,  which  occurs  previous  to  labor  at  term.  Uterine  contrac- 
tions were  induced  with  certainty  and  ease,  but  it  was  found  impossi- 
ble to  foretell  what  time  might  elapse  between  the  commencement  of 
labor  and  the  operation,  which  had  frequently  to  be  performed  more 
than  once.  He  subsequently  modified  this  procedure  by  introducing 
a  flexible  male  catheter,  without  a  stilette,  which  he  allowed  to  re- 
main in  the  uterus  until  contractions  were  excited.  This  plan  is 
much  used  in  Germany,  and  is  now  that  which  is  also  most  fre- 
quently adopted  in  this  country.  It  is  simple  and  very  efficacious, 
pains  coming  on,  almost  invariably,  within  24  hours  after  the  cathe- 
ter or  bougie  is  introduced.  A  theoretical  objection  is  the  possi- 
bility of  the  catheter  separating  a  portion  of  the  placenta  and  giving 
rise  to  hemorrhage ;  but  in  practice  this  has  not  been  found  to  occur, 
and  the  risk  might  generally  be  avoided  by  introducing  the  catheter 
at  a  distance  from  the  placenta,  the  probable  situation  of  which  has 
been  ascertained  by  auscultation.  The  more  deeply  the  catheter  is 
29 


442  OBSTETRIC  OPERATIONS. 

introduced,  the  more  certain  and  rapid  is  its  effect,  and  not  less  than 
7  inches  should  be  pushed  up  within  the  os.  It  is  not  always  easy 
to  insert  it  so  far,  especially  if  a  flexible  catheter  be  used,  which  is 
apt  to  be  too  pliable  to  pass  upwards  with  ease.  A  solid  bougie — 
male  urethra!  bougie — should,  therefore,  be  employed,  and  I  have 
found  its  introduction  greatly  facilitated  by  anaesthetising  the  patient, 
and  passing  the  greater  part  of  the  hand  into  the  vagina.  In  this 
way  it  can  be  pushed  in  very  gently,  and  without  any  risk  of  injury 
to  the  uterus.  There  is  some  chance  of  rupturing  the  membranes 
while  pushing  it  upwards.  This  accident,  indeed,  cannot  always  be 
avoided,  even  when  the  greatest  care  is  taken ;  but,  when  it  occurs, 
the  puncture  will  be  at  a  distance  from  the  os,  so  that  a  small  portion 
only  of  the  liquor  amnii  will  escape,  and  this  can  scarcely  be  con- 
sidered a  serious  objection.  It  is  always  an  advantage  to  allow  the 
pains  to  come  on  gradually,  and  in  imitation  of  natural  labor.  There- 
fore, if,  after  the  bougie  has  been  inserted  for  a  sufficient  time,  uterine 
contractions  come  on  sufficiently  strongly,  we  may  leave  the  case  to 
be  terminated  naturally ;  or,  if  they  be  comparatively  feeble,  we  may 
resort  to  accelerative  procedures,  viz.,  dilatation  of  the  cervix  by  the 
fluid  bags,  and  subsequently  the  puncture  of  the  membranes.  In 
this  way  we  have  the  labor  completely  under  control ;  and  I  believe 
this  method  will  commend  itself  to  those  who  have  experience  of  it, 
as  the  simplest  and  most  certain  mode  of  inducing  labor  yet  known, 
and  the  one  most  closely  imitating  the  natural  process. 

The  Child  is  Immature  and  Difficult  to  Rear. — It  should  not  be  for- 
gotten that  the  child  is  immature,  and  that  unusual  care  is  likely  to 
be  required  to  rear  it  successfully.  "We  should,  therefore,  be  careful 
to  have  at  hand  all  the  usual  means  of  resuscitation ;  and,  as  the 
mother  may  not  be  able  to  nurse  at  once,  it  would  be  a  good  pre- 
caution to  have  a  healthy  wet  nurse  in  readiness. 


CHAPTEK  II. 

TURNING. 

TURNING,  by  which  we  mean  the  alteration  of  the  position  of  the 
foetus,  and  the  substitution  of  some  other  portion  of  the  body  for 
that  originally  presenting,  is  one  of  the  most  important  of  obstetric 
operations,  and  merits  careful  study.  It  is  also  one  of  the  most 
ancient,  and  was  evidently  known  to  the  Greek  and  Eoman  physi- 
cians. Up  to  the  fifteenth  century,  cephalic  version — that  in  which 
the  head  of  the  foetus  is  brought  over  the  os  uteri — was  almost 
exclusively  practised,  when  Pare  and  his  pupil  Guillemeau  taught 
the  propriety  of  bringing  the  feet  down  first.  It  was  by  the  latter 


TURNING.  443 

physician  especially  that  the  steps  of  the  operation  w^re  clearly 
denned;  and  the  French  have  undoubtedly  the  merit  both  of  per- 
fecting its  performance,  and  of  establishing  the  indications  which 
should  lead  to  its  use.  Indeed,  it  was  then  much  more  frequently 
performed  than  in  later  times,  since  no  other  means  of  effecting  arti- 
ficial delivery  were  known,  which  did  not  involve  the  death  of  the 
child;  and  practitioners,  doubtless,  acquired  great  skill  in  its  per- 
formance, and  were  inclined  to  overrate  its  importance,  and  extend 
its  use  to  unsuitable  cases.  An  opposite  error  was  fallen  into  after 
the  invention  of  the  forceps,  which  for  a  time  led  to  the  abandonment 
of  turning  in  certain  conditions  for  which  it  was  well  adapted,  and 
in  which  it  has  only  of  late  years  been  again  practised. 

Cephalic  version  has,  since  Pare  wrote,  been  recommended  and 
practised  from  time  to  time,  but  the  difficulty  of  performing  it  satis- 
factorily was  so  great  that  it  never  became  an  established  operation. 
Dr.  Braxton  Hicks  has  perfected  a  method  by  which  it  can  be  ac- 
complished with  greater  ease  and  certainty,  and  which  renders  it  a 
legitimate  and  satisfactory  resort  in  suitable  cases.  To  him  we  are 
also  indebted  for  introducing  a  method  of  turning  without  passing 
the  entire  hand  into  the  cavity  of  the  uterus,  which,  under  favorable 
circumstances,  is  not  only  easy  of  performance,  but  deprives  the 
operation  of  one  of  its  greatest  dangers. 

Turning  by  External  and  Internal  Manipulation. — The  possibility 
of  effecting  version  by  external  manipulation  has  been  long  known, 
and  was  distinctly  referred  to  and  recommended  by  Dr.  John  Pechey,1 
so  far  back  as  the  year  1698.  Since  that  time  it  has  been  strongly 
advocated  by  Wigand  and  his  followers;  and  various  authors  in  this 
country,  notably  Sir  James  Simpson,  have  referred  to  the  advantage 
to  be  derived  from  external  manipulation  assisting  the  hand  in  the 
interior  of  the  uterus.  To  Dr.  Hicks,  however,  incontestably  belongs 
the  merit  of  having  been  the  first  distinctly  to  show  the  possibility 
of  effecting  complete  version  by  combined  external  and  internal  mani- 
pulation, of  laying  down  definite  rules  for  its  practice,  and  of  thus 
popularizing  one  of  the  greatest  improvements  in  modern  midwifery. 

Object  and  Nature  of  the  Operation. — The  operation  is  entirely 
dependent  for  success  on  the  fact  that  the  child  in  utero  is  freely 
movable,  and  that  its  position  may  be  artificially  altered  with 
facility.  As  long  as  the  membranes  are  unruptured,  and  the  foetus 
is  floating  in  the  surrounding  fluid  medium,  it  is  liable  to  constant 
changes  in  position,  as  may  be  readily  demonstrated  in  the  latter 
months  of  pregnancy ;  and  the  operation,  under  these  circumstances, 
may  be  performed  with  the  greatest  facility.  Shortly  after  the  liquor 
amnii  has  escaped  there  is  still,  as  a  rule,  no  great  difficulty  in  effect- 
ing version ;  but,  as  the  body  is  no  longer  floating  in  the  surround- 
ing liquid,  its  rotation  must  necessarily  be  attended  with  some 
increased  risk  of  injury  to  the  uterus.  If  the  liquor  amnii  have 
been  long  evacuated,  and  the  muscular  structure  of  the  uterus  be 
strongly  contracted,  the  foetus  may  be  so  firmly  fixed,  that  any 

1  The  Complete  Midwife's  Practice,  p.  142. 


444  OBSTETRIC  OPERATIONS. 

attempt  to  move  it  is  surrounded  with  the  greatest  difficulties,  and 
may  even  fail  entirely,  or  be  attended  with  such  risks  to  the  maternal 
structures  as  to  be  quite  unjustifiable. 

Cases  Suitable  for  the  Operation. — Version  may  be  required  either 
on  account  of  the  mother  or  child  alone  ;  or  it  may  be  indicated  by 
some  condition  imperilling  both,  and  rendering  immediate  delivery 
necessary.  The  chief  cases  in  which  it  is  resorted  to  are  those  of 
transverse  presentation,  where  it  is  absolutely  essential ;  accidental 
or  unavoidable  hemorrhage  ;  certain  cases  of  contracted  pelvis;  and 
some  complications,  especially  prolapse  of  the  funis.  The  special 
indications  for  the  operation  have  been  separately  discussed  under 
these  subjects. 

Statistics  and  Dangers  of  the  Operation. — The  ordinary  statistical 
tables  cannot  be  depended  on  as  giving  any  reliable  results  as  to  the 
risks  of  the  operation.  Taking  all  cases  together,  Dr.  Churchill  esti- 
mates the  maternal  mortality  as  1  in  16,  and  the  infantile  as  1  in  3. 
Like  all  similar  statistics,  they  are  open  to  the  objection  of  not  dis- 
tinguishing between  the  results  of  the  operation  itself,  and  of  the 
cause  which  necessitated  interference.  Still  they  are  sufficient  to 
show  that  the  operation  is  not  free  from  grave  hazards,  and  that  it 
must  not  be  undertaken  without  due  reflection.  The  principal 
dangers  will  be  discussed  as  we  proceed.  It  may  suffice  to  mention 
here  that  those  to  the  mother  must  vary  with  the  period  at  which 
the  operation  is  undertaken.  If  version  be  performed  early,  before 
the  rupture  of  the  membranes,  or,  in  favorable  cases,  without  the 
introduction  of  the  hand  into  the  interior  of  the  uterus,  the  risk 
must  of  course  be  infinitely  less  than  in  those  more  formidable  cases 
in  which  the  waters  have  long  escaped,  and  the  hand  and  arm  have 
to  be  passed  into  an  irritable  arid  contracted  uterus.  But  even  in 
the  most  unfavorable  cases  accidents  may  be  avoided,  if  the  operator 
bear  constantly  in  mind  that  the  principal  danger  consists  in  lace- 
ration of  the  uterus  or  vagina  from  undue  force  being  employed,  or 
from  the  hand  and  arm  not  being  introduced  in  the  axis  of  the  pas- 
sages. There  is  no  operation  in  which  gentleness,  absence  of  all 
hurry,  and  complete  presence  of  mind  are  so  essential.  A  certain 
number  of  cases  end  fatally  from  shock  or  exhaustion,  or  from  sub- 
sequent complications.  As  regards  the  child,  the  mortality  is  little, 
if  at  all,  greater  than  in  original  breech  and  footling  presentations. 
Nor  is  there  any  good  reason  why  it  should  be  so,  seeing  that  cases 
of  turning,  after  the  feet  are  brought  through  the  os,  are  virtually 
reduced  to  those  of  feet  presentation,  and  that  the  mere  version,  if 
effected  sufficiently  soon,  is  not  likely  to  add  materially  to  the  risk 
to  which  the  child  is  exposed. 

Version  by  External  Manipulation. — The  possibility  of  effecting 
version  by  external  manipulation  has  been  recognized  by  various 
authors,  and  was  made  the  subject  of  an  excellent  thesis  by  Wigand, 
who  clearly  described  the  manner  of  performing  the  operation.  In 
spite  of  the  manifest  advantages  of  the  procedure,  and  the  extreme 
facility  with  which  it  can  be  accomplished  in  suitable  cases,  it  has 
by  no  means  become  the  established  custom  to  trust  to  it,  and  prob- 


TURNING.  445 

ably  most  practitioners  have  never  attempted  it,  even  under  the  most 
favorable  conditions.  The  possibility  of  operation  is  based  on  the 
extreme  mobility  of  the  foetus  before  the  membranes  are  ruptured. 
After  the  waters  have  escaped,  the  uterine  walls  embrace  the  foetus 
more  or  less  closely,  and  version  can  no  longer  be  readily  performed 
in  this  manner. 

Cases  suitable  for  the  Operation. — It  may,  therefore,  be  laid  down 
as  a  rule  that  it  should  only  be  attempted  when  the  abnormal  posi- 
tion of  the  foetus  is  detected  before  labor  has  commenced,  or  in  the 
early  stage  of  labor,  when  the  membranes  are  unruptured.  It  is 
also  unsuitable  for  any  but  transverse  presentations,  for  it  is  not 
meant  to  effect  complete  evolution  of  the  foetus,  but  only  to  substi- 
tute the  head  for  the  upper  extremity.  It  is  useless  whenever  rapid 
delivery  is  indicated,  for,  after  the  head  is  brought  over  the  brim, 
the  conclusion  of  the  case  must  be  left  to  the  natural  powers. 

Method  of  Performance. — The  manner  of  detecting  the  presentation 
by  palpation  has  been  already  described  (p.  114),  and  the  success  of 
the  operation  depends  on  our  being  able  to  ascertain  the  positions  of 
the  head  arid  breech  through  the  uterine  walls.  Should  labor  have 
commenced,  and  the  os  be  dilated,  the  transverse  presentation  may  be 
also  made  out  by  vaginal  examination.  Should  the  abnormal  pre- 
sentation be  detected  before  labor  has  actually  begun,  it  is,  in  most 
cases,  easy  enough  to  alter  it,  and  to  bring  the  foetus  into  the  longi- 
tudinal axis  of  the  uterine  cavity.  It  is  seldom,  however,  discovered 
until  labor  has  commenced,  and,  even  if  it  be  altered,  the  child  is  ex- 
tremely apt  to  reassume,  in  a  short  time,  the  faulty  position  in  which 
it  was  formerly  lying.  Still  there  can  be  no  harm  in  making  the 
attempt,  since  the  operation  itself  is  in  no  way  painful,  and  is  abso- 
lutely without  risk  either  to  the  mother  or  child.  When  the  trans- 
verse presentation  is  detected  early  in  labor,  I  believe  it  is  good 
practice  to  endeavor  to  remedy  it  by  external  manipulation,  and,  if 
it  fail,  we  may  at  once  proceed  to  other  and  more  certain  methods 
of  operating.  The  procedure  itself  is  abundantly  simple.  The  pa- 
tient is  placed  on  her  back,  and  the  position  of  the  foetus  ascertained 
by  palpation  as  accurately  as  possible,  in  the  manner  already  indi- 
cated. The  palms  of  the  hands  being  then  placed  over  the  opposite 
poles  of  the  foetus,  by  a  series  of  gentle  gliding  movements,  the  head 
is  pushed  towards  the  pelvic  brim,  while  the  breech  is  moved  in  the 
opposite  direction.  The  facility  with  which  the  foetus  may  some- 
times be  moved  in  this  way  can  hardly  be  appreciated  by  those  who 
have  never  attempted  the  operation.  As  soon  as  the  change  is 
effected,  the  long  diameters  of  the  foetus  and  of  the  uterus  will  cor- 
respond, and  vaginal  examination  will  show  that  the  shoulder  is  no 
longer  presenting,  and  that  the  head  is  over  the  pelvic  brim.  If 
the  os  be  sufficiently  dilated,  and  labor  in  progress,  the  membranes 
should  now  be  punctured,  and  the  position  of  the  foetus  maintained 
for  a  short  time  by  external  pressure,  until  we  are  certain  that  the 
cephalic  presentation  is  permanently  established.  If  labor  be  not  in 
progress,  an  attempt  may  at  least  be  made  to  effect  the  same  object 
by  pads  and  a  binder ;  one  pad  being  placed  on  the  side  of  the  uterus 


446  OBSTETRIC  OPERATIONS. 

in  the  situation  of  the  breech,  and  another  on  the  opposite  side  in 
the  situation  of  the  head. 

Cephalic  Version. — On  account  of  the  difficulty  of  performing  cepha- 
lic version  in  the  manner  usually  recommended,  it  has  practically 
scarcely  been  attempted,  and,  with  the  exception  of  some  more  recent 
authors,  it  is  generally  condemned  by  writers  on  systematic  mid- 
wifery. Still  the  operation  offers  unquestionable  advantages  in  those 
transverse  presentations  in  which  rapid  delivery  is  not  necessary, 
and  in  which  the  only  object  of  interference  is  the  rectification  of 
malposition;  for,  if  successful,  the  child  is  spared  the  risk  of  being 
drawn  footling  through  the  pelvis.  The  objections  to  cephalic  ver- 
sion are  based  entirely  on  the  difficulty  of  performance;  and,  un- 
doubtedly, to  introduce  the  hand  within  the  uterus,  search  for,  seize, 
and  afterwards  place  the  slippery  head  in  the  brim  of  the  pelvis, 
could  not  be  an  easy  process,  even  under  the  most  favorable  circum- 
stances, and  must  always  be  attended  by  considerable  risk  to  the 
mother.  Velpeau,  who  strongly  advocated  the  operation,  was  of 
opinion  that  it  might  be  more  easily  accomplished  by  pushing  up  the 
presenting  part,  than  by  seizing  and  bringing  down  the  head.  Wi- 
gaiid  more  distinctly  pointed  out  that  the  head  could  be  brought  to 
a  "proper  position  by  external  manipulation,  aided  by  the  fingers  of 
one  hand  within  the  vagina.  Braxton  Hicks  has  laid  down  clear 
rules  for  its  performance,  which  render  cephalic  version  easy  to  ac- 
complish under  favorable  conditions,  and  will  doubtless  cause  it  to 
become  a  recognized  mode  of  treating  malpositions.  The  number  of 
cases,  however,  in  which  it  can  be  performed  must  always  be  limited, 
since,  as  in  turning  by  external  manipulation  alone,  it  is  necessary 
that  the  liquor  amnii  should  be  still  retained,  or  at  least  have  only 
recently  escaped ;  that  the  presentation  be  freely  movable  above  the 
pelvic  brim;  and  that  there  be  no  necessity  for  rapid  delivery.  Dr. 
Hicks  does  not  believe  protrusion  of  the  arm  to  be  a  contra-indica- 
tion,  and  advises  that  it  should  be  carefully  replaced  within  the 
uterus.  When,  however,  protrusion  of  the  arm  has  occurred,  the 
thorax  is  so  constantly  pushed  down  into  the  pelvis  that  replacement 
can  neither  be  safe  nor  practicable,  except  under  unusually  favorable 
conditions,  and  podalic  version  will  be  necessary. 

Method  of  Performance. — It  is  impossible  to  describe  the  method 
of  performing  cephalic  version  more  concisely  and  clearly  than  in 
Dr.  Hicks's  own  words.  "Introduce,"  he  says,  "the  left  hand  into 
the  vagina,  as  in  podalic  version;  place  the  right  hand  on  the  out- 
side of  the  abdomen,  in  order  to  make  out  the  position  of  the  foetus, 
and  the  direction  of  its  head  and  feet.  Should  the  shoulder,  for 
instance,  present,  then  push  it  with  one  or  two  ringers  in  the  direc- 
tion of  the  feet.  At  the  same  time  pressure  with  the  other  hand 
should  be  exerted  on  the  cephalic  end  of  the  child.  This  will  bring 
the  head  down  to  the  os;  then  let  the  head  be  received  on  the  tips 
of  the  inside  fingers.  The  head  will  play  like  a  ball  between  the 
two  hands;  it  will  be  under  their  command,  and  can  be  placed  in 
almost  any  part  at  will.  Let  the  head  then  be  placed  over  the  os, 
taking  care  to  rectify  any  tendency  to  face  presentation.  It  is  as 


TURNING.  447 

well,  if  the  breech  will  not  rise  to  the  fimdus  readily  after  the  head 
is  fairly  in  the  os,  to  withdraw  the  hand  from  the  vagina,  and  with 
it  press  up  the  breech  from  the  exterior.  The  hand  which  is  re- 
taining gently  the  head  from  the  outside  should  continue  there  for 
some  little  time,  till  the  pains  have  insured  the  retention  of  the  child 
in  its  new  position  and  the  adaptation  of  the  uterine  walls  to  its  new 
form.  Should  the  membranes  be  perfect,  it  is  advisable  to  rupture 
them  as  soon  as  the  head  is  at  the  os  uteri;  during  their  flow  and 
after  the  head  will  move  easily  into  its  proper  position." 

The  procedure  thus  described  is  so  simple,  and  would  occupy  so 
short  a  time,  that  there  can  be  no  objection  to  trying  it.  Should  we 
fail  in  our  endeavors,  we  shall  not  be  in  a  worse  position  for  effecting 
delivery  by  podalic  version,  which  can  be  proceeded  with  without 
withdrawing  the  hand  from  the  vagina,  or  in  any  way  altering  the 
position  of  the  patient. 

Podalic  Version. — The  method  of  performing  podalic  version  varies 
with  the  nature  of  each  particular  case.  In  describing  the  operation, 
it  has  been  usual  to  divide  the  cases  into  those  in  which  the  circum- 
stances are  favorable,  and  the  necessary  manoeuvres  easily  accom- 
plished; and  those  in  which  there  are  likely  to  be  considerable  diffi- 
culties, and  increased  risk  to  the  mother.  This  division  is  eminently 
practicable,  since  nothing  can  be  more  variable  than  the  circum- 
stances under  which  version  may  be  required.  Before  describing 
the  steps  of  the  operation,  it  may  be  well  to  consider  some  general 
conditions  applicable  to  all  cases  alike. 

Position  of  the  Patient. — In  this  country  the  ordinary  position  on 
the  left  side  is  usually  employed.  On  the  Continent  and  in  America 
the  patient  is  placed  on  her  back,  with  the  legs  supported  by  assist- 
ants, as  in  lithotomy.  The  former  position  is  preferable,  not  only 
as  a  matter  of  custom,  and  as  involving  much  less  fuss  and  exposure 
of  the  person,  but  because  it  admits  of  both  the  operator's  hands 
being  more  easily  used  in  concert.  In  certain  difficult  cases,  when 
the  liquor  amnii  has  escaped,  arid  the  back  of  the  child  is  turned 
towards  the  spine  of  the  mother,  the  dorsal  decubitis  presents  some 
advantages  in  enabling  the  hand  to  pass  more  readily  over  the  body 
of  the  child ;  but  such  cases  are  comparatively  rare.  The  patient 
should  be  brought  to  the  side  of  the  bed,  across  which  .she  should 
be  laid,  with  the  hips  projecting  over,  and  parallel  to,  the  edge,  the 
knees  being  flexed  towards  the  abdomen,  and  separated  from  each 
other  by  a  pillow,  or  by  an  assistant.  Assistants  should  also  be 
placed  so  as  to  restrain  the  patient  if  necessary,  and  prevent  her 
involuntarily  starting  from  the  operator,  as  this  might  not  only 
embarrass  his  movements,  but  be  the  cause  of  serious  injury. 

Administration  of  Anaesthetics. — The  exhibition  of  anaesthetics  is 
peculiarly  advantageous.  There  is  nothing  which  tends  to  facilitate 
the  steps  of  the  process  so  much  as  stillness  on  the  part  of  the 
patient,  and  the  absence  of  strong  uterine  contraction.  When  the 
vagina  is  very  irritable  and  the  uterus  firmly  contracted  round  the 
body  of  the  child,  complete  anaesthesia  may  enable  us  to  effect  ver- 
sion, when  without  it  we  should  certainly  fail. 


448  OBSTETRIC  OPERATIONS. 

Period  when  the  Operation  should  be  Undertaken. — The  most  favor- 
able time  for  operating  is  when  the  os  is  fully  dilated,  before,  or  im- 
mediately after,  the  rupture  of  the  membranes  and  the  discharge  of 
the  liquor  amnii.  The  advantage  gained  by  operating  before  the 
waters  have  escaped  cannot  be  overstated,  since  we  can  then  make 
the  child  rotate  with  great  facility  in  the  fluid  medium  in  which  it 
floats.  In  the  ordinary  operation,  in  which  the  hand  is  passed  into 
the  uterus,  it  is  essential  to  wait  until  the  os  is  of  sufficient  size  to 
admit  its  being  introduced  with  safety.  This  may  generally  be  done 
when  the  os  is  the  size  of  a  crown-piece,  especially  if  it  be  soft  and 
yielding. 

Choice  of  Hand  to  be  used. — The  practice  followed  with  regard  to 
the  hand  to  be  used  in  turning  varies  considerably.  Some  accoucheurs 
always  employ  the  right  hand,  others  the  left,  and  some  one  or  other, 
according  to  the  position  of  the  child.  In  favor  of  the  right  hand, 
it  is  said  that  most  practitioners  have  more  power  with  it,  and  are 
able  to  use  it  with  greater  gentleness  and  delicacy.  In  transverse 
presentations,  if  the  abdomen  of  the  child  be  placed  anteriorly,  the 
right  hand  is  said  to  be  the  proper  one  to  use,  on  account  of  the 
greater  facility  with  which  it  can  be  passed  over  the  front  of  the 
child ;  and  in  difficult  cases  of  this  kind,  when  we  are  operating  with 
the  patient  on  her  back,  it  certainly  can  be  employed  with  more  pre- 
cision than  the  left.  In  all  ordinary  cases,  however,  the  left  hand 
can  be  introduced  much  more  easily  in  the  axis  of  the  passages,  the 
back  of  the  hand  adapts  itself  readily  to  the  curve  of  the  sacrum, 
and,  even  when  the  child's  abdomen  lies  anteriorly,  it  can  be  passed 
forwards  without  difficulty  so  as  to  seize  the  feet.  These  advantages 
are  sufficient  to  recommend  its  use,  and  very  little  practice  is  re- 
quired to  enable  the  practitioner  to  manipulate  with  it  as  freely  as 
with  the  right.  If,  in  addition,  we  remember  that  the  right  hand  is 
required  to  operate  on  the  foetus  through  the  abdominal  walls — and 
this  is  a  point  which  should  never  be  forgotten — we  shall  have 
abundant  reasons  for  laying  it  down  as  a  rule  that  the  left  hand 
should  generally  be  employed.  Before  passing  the  hand  and  arm 
they  should  be  freely  lubricated,  with  the  exception  of  the  palm, 
which  is  left  untouched  to  admit  of  a  firm  grasp  being  taken  of  the 
foetal  limbs.  It  is  also  advisable  to  remove  the  coat,  and  bare  the 
arm  as  high  as  the  elbow. 

As  it  should  be  a  cardinal  rule  to  resort  to  the  simplest  procedure 
when  practicable,  it  will  be  well  to  consider  first  the  method  by  com- 
bined external  and  internal  manipulation,  without  passing  the  hand 
into  the  uterus,  and  subsequently  that  which  involves  the  introduc- 
tion of  the  hand. 

Turning  by  Combined  External  and  Internal  Manipulation. — To 
effect  podalic  version  by  the  combined  method  it  is  an  essential  pre- 
liminary to  ascertain  the  situation  of  the  foetus  as  accurately  as  pos- 
sible. It  will  generally  be  easy,  in  transverse  presentation,  to  make 
out  the  breech  and  the  head  by  palpation;  while,  in  head  presenta- 
tions, the  fontanelles  will  show  to  which  side  of  the  pelvis  the  face 
is  turned.  The  left  hand  is  then  to  be  passed  carefully  into  the 


TURNING. 


449 


vagina,  in  the  axis  of  the  canal,  to  a  sufficient  extent  to  admit  of  the 
fingers  passing  freely  into  the  cervix.  To  effect  this,  it  is  not  always 
necessary  to  insert  the  whole  hand,  three  or  four  fingers  being  gen- 
erally sufficient. 

If  the  head  lie  in  the  first  or  fourth  position,  push  it  upwards  and 
to  the  left ;  while  the  other  hand,  placed  externally  on  the  abdomen, 

FIG.  142. 


First  Stage  of  Bi-polar  Version. — Elevation  of  the   Head  and  Depression  of  the  Breech. 

(After  Barnes.) 

depresses  the  breech  towards  the  right  (Fig.  143).  By  this  means 
we  act  simultaneously  on  both  extremities  of  the  child's  body,  and 
easily  alter  its  position.  The  breech  is  pushed  down  gently  but 
firmly,  by  gliding  the  hand  over  the  abdominal  wall.  The  head  will 
now  pass  out  of  reach,  and  the  shoulder  will  arrive  at  the  os,  and 
will  lie  on  the  tips  of  the  fingers.  This  is  similarly  pushed  upwards 
in  the  same  direction  as  the  head  (Fig.  143),  the  breech  at  the  same 
time  being  still  further  depressed,  until  the  knee  comes  within  reach 
of  the  fingers,  when  (the  membranes  being  now  ruptured,  if  still 
unbroken)  it  is  seized  and  pulled  down  through  the  os  (Fig.  144). 
Occasionally  the  foot  comes  immediately  over  the  os,  when  it  can  be 
seized  instead  of  the  knee.  Version  may  be  facilitated  by  changing 
the  position  of  the  external  hand,  and  pushing  the  head  upwards 
from  the  iliac  fossa,  instead  of  continuing  the  attempt  to  depress  the 
breech  (Figs.  144  and  145).  These  manipulations  should  always  be 
carried  on  in  the  intervals,  and  desisted  from  when  the  pains  come 


450 


OBSTETRIC    OPERATIONS. 


on  ;  and  when  the  pains  recur  with  great  force  and  frequency,  the 
advantage   of  chloroform   will   be   particularly  apparent.     In   the 


FIG.  143. 


Second  Stage  of  Bi-polar  Version. — Elevation  of  the  shoulders  and  depression  of  the  breech. 

(After  Barues.) 

second  and  third  positions,  the  steps  of  the  operation  should  be  re- 
versed; the  head  is  pushed  upwards  and  to  the  right,  the  breech 

FIG.  144. 


Third  Stage  of  Bi-polar  Version. — Seizure  of  the  knee  and  partial  elevation  of  the  head. 

(After  Barnes.) 

downwards  and  to  the  left.     When  the  position  cannot  be  made  out 
with  certainty,  it  is  well  to  assume  that  it  is  the  first,  since  that  is 


TURNING. 


451 


the  one  most  frequently  met  with  ;  and  even  if  it  be  not,  no  great 
inconvenience  is  likely  to  occur.  If  the  os  be  not  sufficiently  open 
to  admit  of  delivery  being  concluded,  the  lower  extremity  can  be 
retained  in  its  new  position  with  one  finger,  until  dilatation  is  sum- 


FIG.  145. 


Fourth  Stage  of  Bi-polar  Version. — Drawing  down  of  leg  and  completion  of  version.     (After 

Barnes.) 

ciently  advanced,  or  until  the  uterus  has  permanently  adapted  itself 
to  the  altered  position  of  the  child,  either  of  which  results  will  gene- 
rally be  effected  in  a  short  space  of  time. 

In  transverse  presentations  the  same  means  are  to  be  adopted,  the 
shoulder  being  pushed  upwards  in  the  direction  of  the  head,  while 
the  breech  is  depressed  from  without.  This  is  frequently  sufficient 
to  bring  the  knees  within  reach,  especially  if  the  membranes  are 
entire,  but  version  is  much  facilitated  by  pressing  the  head  upwards 
from  without,  alternately  with  depression  of  the  breech.  If  the 
liquor  amnii  has  escaped,  and  the  uterus  is  firmly  contracted  round 
the  body  of  the  child,  it  will  be  found  impossible  to  effect  an  altera- 
tion in  its  position  without  the  introduction  of  the  hand,  and  the 
ordinary  method  of  turning  must  be  employed.  The  peculiar  advan- 
tage of  the  combined  process  is,  that  it  in  no  way  interferes  with 
the  latter,  for,  should  it  not  succeed,  the  hand  can  be  passed  on  into 
the  uterus  without  withdrawal  from  the  vagina  (provided  the  os  be 
sufficiently  dilated),  and  the  feet  or  knees  seized  and  brought  down. 

Podalic  Version  when  the  Hand  is  Introduced  into  the  Uterus. — Turn- 
ing, with  the  hand  introduced  into  the  uterus,  provided  the  waters 


CQLLlZtalE   01 

r-  u  \  s  i  c  i  (\  K 


452  OBSTETRIC  OPERATIONS. 

have  not  or  have  only  recently  escaped,  and  the  os  be  sufficiently 
dilated,  is  an  operation  generally  performed  with  ease. 

Introduction  of  the  Hand. — The  first  step,  and  one  of  the  most 
important,  is  the  introduction  of  the  hand  and  arm.  The  fingers 
having  been  pressed  together  in  the  form  of  a  cone,  the  thumb  lying 
between  the  rest  of  the  fingers,  the  hand,  thus  reduced  to  the  smallest 
possible  dimensions,  is  slowly  and  carefully  passed  into  the  vagina, 
in  the  axis  of  the  outlet,  in  an  interval  between  the  pains,  and  passed 
onwards  in  the  same  cautious  manner,  and  with  a  semi-rotatory 
motion,  until  it  lies  entirely  within  the  vagina,  the  direction  of  intro- 
duction being  gradually  changed  from  the  axis  of  the  outlet  to  that 
of  the  brim.  If  uterine  contractions  come  on,  the  hand  should 
remain  passive  until  they  are  over.  It  should  ever  be  borne  in 
mind,  as  one  of  the  fundamental  rules  in  performing  version,  that 
we  should  act  only  in  the  absence  of  pains,  and  then  with  the  utmost 
gentleness — all  force  and  violent  pushing  being  avoided.  The  hand, 
still  in  the  form  of  a  cone,  having  arrived  at  the  os,  if  this  be  suffi- 
ciently dilated,  may  be  passed  through  at  once.  If  the  os  be  not 
quite  open,  but  dilatable,  the  points  of  the  fingers  may  be  gently 
insinuated,  and  occasionally  expanded,  so  as  to  press  it  open  suffi- 
ciently to  permit  the  rest  of  the  hand  to  pass.  While  this  is  being 
done,  the  uterus  should  be  steadied  by  the  other  hand  placed  exter- 
nally, or  by  an  assistant.  If  the  presentation  should  not  previously 
have  been  made  out  with  accuracy,  we  can  now  ascertain  how  to 
pass  the  hand  onwards,  so  that  its  palmar  surface  may  correspond 
with  the  abdomen  of  the  child. 

Rupture  of  the  Membranes. — The  membranes  should  now  be  rup- 
tured— if  possible  during  the  absence  of  pain — so  as  to  prevent  the 
waters  being  forced  out.  The  hand  and  arm  form  a  most  efficient 
plug,  and  the  liquor  amnii  cannot  escape  in  any  quantity.  Some 
practitioners  recommend  that,  before  rupturing  the  membranes,  the 
hand  should  be  passed  onwards  between  them  and  the  uterine  walls, 
until  we  reach  the  feet.  By  so  doing  we  run  the  risk  of  separating 
the  placenta ;  besides  we  have  to  introduce  the  hand  much  further 
than  may  be  necessary,  since  the  knees  are  often  found  lying  quite 
close  to  the  os.  As  soon  as  the  membranes  are  perforated,  the  hand 
can  be'  passed  on  in  search  of  the  feet  (Fig.  146).  At  this  stage  of 
the  operation  increased  care  is  necessary  to  avoid  anything  like 
force ;  and  should  a  pain  come  on,  the  hand  must  be  kept  perfectly 
flat  and  still,  and  rather  pressed  on  the  body  of  the  child  than  on  the 
uterus.  If  the  pains  be  strong,  much  inconvenience  may  be  felt  from 
the  compression;  and,  were  the  onward  movement  continued,  or  the 
hand  even  kept  bent  in  the  conical  form  in  which  it  was  introduced, 
rupture  of  the  uterine  walls  might  easily  be  caused.  This  is  not 
likely  to  occur  in  the  class  of  cases  now  under  consideration,  for  it 
is  chiefly  when  the  waters  have  long  escaped  that  the  progress  of  the 
hand  is  a  matter  of  difficulty.  Valuable  assistance  may  now  be  given 
by  pressing  the  breech  downwards  from  without,  so  as  to  bring  the 
knees  or  feet  more  easily  within  the  reach  of  the  internal  hand. 
Having  arrived  at  the  knees  or  feet,  they  may  be  seized  between  the 

KT 


TURNING. 


453 


fingers,  and  drawn  downwards  in  the  absence  of  a  pain  (Fig.  1-iT). 
This  will  cause  the  foetus  to  revolve  on  its  axis,  the  breech  will  de- 
scend, and,  at  the  same  time,  the  ascent  of  the  head  may  be  assisted 
by  the  right  hand  from  without.  It  is  a  question  with  many  ac- 


Fio.  146. 


Seizure  of  the  Feet  when  the  Hand  is  Introduced  into  the  Uterus. 

coucheurs  which  part  of  the  inferior  extremities  should  be  seized 
and  brought  down.  Some  recommend  us  to  seize  both  feet,  others 
prefer  one  only,  while  some  advise  the  seizure  of  one  or  both  knees. 
In  a  simple  case  of  turning,  before  the  escape  of  the  waters,  it  does 
not  much  matter  which  of  these  plans  is  followed,  since  version  is 
accomplished  with  the  greatest  ease  by  any  one  of  them.  The  seizure 
of  the  knee,  however,  instead  of  the  feet,  offers  certain  advantages 
which  should  not  be  overlooked.  It  is  generally  more  accessible, 
affords  a  better  hold  (the  fingers  being  inserted  in  the  flexure  of  the 
ham),  and,  being  nearer  the  spine,  traction  acts  more  directly  on  the 
body  of  the  child.  Any  danger  of  mistaking  the  knee  for  the  elbow 
may  be  obviated  by  remembering  the  simple  rule  that  the  salient 
angle  of  the  former  looks  towards  the  head  of  the  child,  of  the  latter 
towards  its  feet.  Certain  advantages  may  also  be  gained  by  bring- 
ing down  one  foot  or  knee  only,  instead  of  both.  When  one  inferior 
extremity  remains  flexed  on  the  body  of  the  child,  the  part  which 
has  to  pass  through  the  os  is  larger  than  when  both  legs  are  drawn 
down,  and  consequently  the  os  is  more  perfectly  dilated,  and  less 


454  OBSTETRIC  OPERATIONS. 

difficulty  is  likely  to  be  experienced  in  the  delivery  of  the  rest  of  the 
body,  so  that  the  risk  to  the  child  is  materially  diminished. 

FIG.  147. 


Drawing  down  of  the  Feet  and  Completion  of  Version. 

Choice  of  Leg  to  be  brought  down  in  Transverse  Presentations.— 
Simpson,  whose  views  have  been  adopted  by  Barnes  and  other  writers, 
recommend  the  seizing,  if  possible,  in  arm  presentations,  of  the  knee 
farthest  from  and  opposite  to  the  presenting  arm,  as  by  this  means 
the  body  is  turned  round  on  its  longitudinal  axis,  and  the  presenting 
arm  and  shoulder  more  easily  withdrawn  from  the  os.  Dr.  Galabin 
has  carefully  investigated  this  point  in  a  recent  paper,1  and  contends 
that  there  is  a  greater  mechanical  advantage  in  seizing  the  leg  which 
is  nearest  to,  and  on  the  same  side  as,  the  presenting  arm,  and  this, 
moreover,  is  generally  more  readily  done. 

Management  of  the  Case  after  Version. — As  soon  as  the  head  has 
reached  the  fundus,  and  the  lower  extremity  is  brought  through  the 
os,  the  case  is  converted  into  a  foot  or  knee  presentation,  and  it  comes 
to  be  a  question  whether  delivery  should  now  be  left  to  nature  or 
terminated  by  art.  This  must  depend  to  a  certain  extent  on  the  case 
itself,  and  on  the  cause  which  necessitated  version,  but  generally,  it 

1  Obst.  Trans.,  vol.  xix.  1877. 


TURNING. 


455 


will  be  advisable  to  finish  delivery  without  unnecessary  delay.  To 
accomplish  this,  downward  traction  is  made  during  the  pains,  and 
desisted  from  in  the  intervals  (Fig.  148).  As  the  umbilical  cord 


FIG.  148. 


Showing  the  Completion  of  Version.     (After  Barnes.) 

appears,  a  loop  should  be  drawn  down  ;  and  if  the  hands  be  above 
the  head,  they  must  be  disengaged  and  brought  over  the  face,  in  the 
same  manner  as  in  an  ordinary  footling  presentation.  The  manage- 
ment of  the  head,  after  it  descends  into  the  cavity  of  the  pelvis,  must 
also  be  conducted  as  in  labors  of  that  description. 

Turning  in  Placenta  Prsevia. — In  cases  of  placenta  praevia  the  os 
will,  as  a  rule,  be  more  easily  dilatable  than  in  transverse  presenta- 
tions. Hicks's  method  offers  the  great  advantage  of  enabling  us  to 
perform  version  much  sooner  than  was  formerly  possible,  since  it 
only  requires  the  introduction  of  one  or  two  fingers  into  the  os  uteri. 
Should  we  not  succeed  by  it,  and  the  state  of  the  patient  indicates 
that  delivery  is  necessary,  we  have  at  our  command,  in  the  fluid 
dilators,  a  means  of  artificially  dilating  the  os  uteri  which  can  be 
employed  with  ease  and  safety.  If  we  have  to  do  with  a  case  of 
entire  placental  presentation,  the  hand  should  be  passed  at  that  point 
where  the  placenta  seems  to  be  least  attached.  This  will  always  be 
better  than  attempting  to  perforate  its  substance,  a  measure  some- 
times recommended,  but  more  easily  performed  in  theory  than  in 
practice.  If  the  placenta  only  partially  present,  the  hand  should,  of 


456  OBSTETRIC  OPERATIONS. 

course  be  inserted  at  its  free  border.  It  will  frequently  be  advisable 
not  to  hasten  delivery  after  the  feet  have  been  brought  through  the 
os,  for  they  form  of  themselves  a  very  efficient  plug,  and  effectually 
prevent  further  loss  of  blood ;  while,  if  the  patient  be  much  ex- 
hausted, she  may  have  her  strength  recruited  by  stimulants,  etc., 
before  the  completion  of  delivery. 

Turning  in  Abdomino- anterior  Positions. — In  abdomiuo-anterior 
positions,  in  which  the  waters  have  escaped,  and  in  which,  therefore, 
some  difficulty  may  be  reasonably  anticipated,  the  operation  is  gener- 
ally more  easily  performed  with  the  patient  on  her  back ;  the  right 
hand  is  then  introduced  in  the  uterus,  and  the  left  employed  exter- 
nally (Fig.  149).  In  this  way  the  internal  hand  has  to  be  passed  a 

FIG.  149. 


Showing  the  Use  of  the  Eight  Hand  in  Abdomino-auterior  Position. 

shorter  distance,  and  in  a  less  constrained  position.  The  operator 
then  sits  in  front  of  the  patient,  who  is  supported  at  the  edge  of  the 
bed  in  the  lithotomy  position  with  the  thighs  separated,  and  the  right 
hand  is  passed  up  behind  the  pubis,  and  over  the  abdomen  of  the  child. 
Difficult  Cases  of  Arm  Presentation. — The  difficulties  of  turning 
culminate  in  those  unfavorable  cases  of  arm  presentation  in  which 
the  membranes  have  been  long  ruptured,  the  shoulder  and  arm 
pressed  down  into  the  pelvis,  and  the  uterus  contracted  round  the 
body  of  the  child.  The  uterus  being  firmly  and  spasmodically  con- 
tracted, the  attempt  to  introduce  the  hand  often  only  makes  matters 
worse,  by  inducing  more  frequent  and  stronger  pains.  Even  if  the 
hand  and  arm  be  successfully  passed,  much  difficulty  is  often  ex- 
perienced in  causing  the  body  of  the  child  to  rotate ;  for  we  have  no 
longer  the  fluid  medium  present  in  which  it  floated  and  moved  with 


TURNING.  457 

ease,  and  the  arm  of  the  operator  may  be  so  cramped  and  pained, 
by  the  pressure  of  the  uterine  walls,  as  to  be  rendered  almost  power- 
less. The  risk  of  laceration  is  also  greatly  increased,  and  the  care 
necessary  to  avoid  so  serions  an  accident  acids  much  to  the  difficulty 
of  the  operation. 

Value  of  Anaesthesia  in  Relaxing  the  Uterus. — In  these  perplexing 
cases  various  expedients  have  been  tried  to  cause  relaxation  of  the 
spasmodically  contracted  uterine  fibres,  such  as  copious  venesection 
in  the  erect  attitude  until  fainting  is  induced,  warm  baths,  tartar 
emetic,  and  similar  depressing  agents.  None  of  these,  however,  are 
so  useful  as  the  free  administration  of  chloroform,  which  has  practi- 
cally superseded  them  all,  and  often  answers  most  effectually  when 
given  to  its  full  surgical  extent. 

Mode  of  Procedure. — The  hand  must  be  introduced  with  the  pre- 
cautions already  described.  If  the  arm  be  completely  protruded 
into  the  vagina,  we  should  pass  the  hand  along  it  as  a  guide,  and  its 
palmar  syrface  will  at  once  indicate  the  position  of  the  child's  abdo- 
men. No  advantage  is  gained  by  amputation,  as  is  sometimes  recom- 
mended. When  the  os  is  reached,  the  real  difficulties  of  the  operation 
commence,  and,  if  the  shoulder  be  firmly  pressed  down  into  the  brim 
of  the  pelvis,  it  may  not  be  easy  to  insinuate  the  hand  past  it.  It  is 
allowable  to  repress  the  presenting  part  a  little,  but  with  extreme 
caution,  for  fear  of  injuring  the  contracted  uterine  parietes.  It  is 
better  to  insinuate  the  hand  past  the  obstruction,  which  can  generally 
be  done  by  patient  and  cautious  endeavors.  Having  succeeded  in 
passing  the  shoulder,  the  hand  is  to  be  pressed  forward  in  the  intervals, 
being  kept  perfectly  flat  and  still  on  the  body  of  the  foetus  when  the 
pains  come  on.  It  is  much  safer  to  press  on  it  than  on  the  uterine 
walls,  which  might  readily  be  lacerated  by  the  projecting  knuckles. 
When  the  hand  has  advanced  sufficiently  far,  it  will  be  better,  for 
the  reasons  already  mentioned,  to  seize  and  bring  down  one  knee 
only. 

Management  of  Cases  in  ivhich  the  Foot  is  brought  down  but  the  Foetus 
will  not  Revolve. — Even  when  the  foot  has  been  seized  and  brought 
through  the  os,  it  is  by  no  means  always  easy  to  make  the  child 
revolve  on  its  axis,  as  the  shoulder  is  often  so  firmly  fixed  in  the 
pelvic  brim  as  not  to  rise  towards  the  fundus.  Some  assistance  may 
be  derived  from  pushing  the  head  upwards  from  without,  which,  of 
course,  would  raise  the  shoulder  along  with  it.  If  this  should  fail, 
we  may  effect  our  object  by  passing  a  noose  of  tape  or  wire  ribbon 
round  the  limb,  by  which  traction  is  made  downwards  and  back- 
wards; at  the  same  time,  the  other  hand  is  passed  into  the  vagina  to 
displace  the  shoulder  and  push  it  out  of  the  brim.  It  is  evident  that 
this  cannot  be  done  as  long  as  the  limb  is  held  by  the  left  hand,  as 
there  is  no  room  for  both  hands  to  pass  into  the  vagina  at  the  same 
time.  By  this  manoeuvre  version  may  be  often  completed,  when  the 
foetus  cannot  be  turned  in  the  ordinary  way.  Various  instruments 
have  been  invented,  both  for  passing  a  lac  round  the  child's  limb,  and 
for  repressing  the  shoulder,  but  none  of  them  can  compete,  either  in 
facility  of  use  or  safety,  with  the  hand  of  the  accoucheur. 
30 


458  OBSTETRIC  OPERATIONS. 

Should  all  attempts  at  version  fail,  no  resource  is  left  but  the 
mutilation  of  the  child,  either  by  evisceration  or  decapitation.  This 
extreme  measure  is,  fortunately,  seldom  necessary,  as  with  due  care 
version  may  generally  be  effected,  even  under  the  most  unfavorable 
circumstances. 


CHAPTER  III. 

THE  FORCEPS. 

OF  all  obstetric  operations  the  most  important,  because  the  most 
truly  conservative  both  to  the  mother  and  child,  is  the  application 
of  the  forceps.  In  modern  midwifery  the  use  of  the  instrument  is 
much  extended,  and  it  is  now  applied  by  some  of  our  most  expe- 
rienced accoucheurs  with  a  frequency  which  older  practitioners  would 
have  strongly  reprobated.  That  the  injudicious  and  unskilful  use  of 
the  forceps  is  capable  of  doing  much  harm,  no  one  will  for  a  moment 
deny.  This,  however,  is  not  a  reason  for  rejecting  the  recommenda- 
tion of  those  who  advise  a  more  frequent  resort  to  the  operation,  but 
rather  for  urging  on  the  practitioner  the  necessity  of  carefully  study- 
ing the  manner  of  performing  it,  and  of  making  himself  familiar  with 
the  cases  in  which  it  is  easy  or  the  reverse.  Nothing  but  practice — 
at  first  on  the  dummy,  and  afterwards  in  actual  cases — can  impart 
the  operative  dexterity  which  it  should  be  the  aim  of  every  obstetri- 
cian to  acquire,  and  without  which  there  can  be  no  assurance  of  his 
doing  his  duty  to  his  patient  efficiently. 

Description  of  the  Instrument. — The  forceps  may  best  be  described 
as  a  pair  of  artificial  hands,  by  jvhich  the  foetal  head  may  be  grasped 
and  drawn  through  the  maternal  passages  by  a  vis  a  fronte,  when 
the  vis  a  teryo  is  deficient.  This  description  will  impress  on  the  mind 
the  important  action  of  the  instrument  as  a  tractor,  to  which  all  its 
other  powers  are  subservient.  The  forceps  consists  of  two  separate 
blades  of  a  curved  form,  adapted  to  fit  the  child's  head ;  a  lock  by 
which  the  blades  are  united  after  introduction ;  and  handles  which 
are  grasped  by  the  operator,  and  by  means  of  which  traction  is  made. 
It  would  be  a  wearisome  and  unsatisfactory  task  to  dwell  on  all  the 
modifications  of  the  instrument  which  have  been  made,  which  are  so 
numerous  as  to  make  it  almost  appear  as  if  no  one  could  practise 
midwifery  with  the  least  pretension  to  eminence,  unless  he  has 
attached  his  name  to  a  new  variety  of  forceps. 

The  Short  Forceps. — The  original  instrument,  invented  by  the 
Chamberlens,  may  be  looked  upon  as  the  type  of  the  short  straight 
forceps,  which  has  been  more  employed  than  any  other,  and  which, 
perhaps,  finds  its  best  representative  in  the  short  forceps  of  Denmaii 


THE    FORCEPS. 


459 


(Fig.  150).     Indeed  the  only  essential  difference  between  the  two  is 

the  lock  of  the  latter,  originally  invented  by  Smellie,  which  is  so 

excellent  that  it  has  been  adopted  in  all  British  forceps;  and  which, 

for  facility  of  juncture,  is  much  superior  to  either  the  French  pivot, 

or  the  German  lock,  while  for  firmness 

it  is,  for  all  practical  purposes,  as  good  as 

either.     In  this  instrument  the  blades 

are  7,  the  handles  4f  inches  in  length ; 

the  extremities  of  the  blades  are  exactly 

1  inch  apart,  and  the  space  between 

them,  at  their  widest  part,  is  2f  inches. 

The  blades  measure  If  inches  at  their 

greatest   breadth,   and   spring   with   a 

regular  sweep  directly  from  the  lock, 

there  being  no  shank.     The  blades  are 

formed  of  the  best  and  most   highly 

tempered  steel,  to  resist  the  strain  to 

which  they  are  occasionally  subjected, 

and  they  are  smooth  and  rounded  on 

their  inner  surface,  to  obviate  the  risk 

of  injury  to  the  scalp  of  the  child. 

Advantages  claimed  for  this  Form,  of 
Instrument. — The  special  advantage 
claimed  for  this  form  of  instrument  is, 
that,  the  two  halves  being  precisely 
similar,  no  care  or  forethought  is  re- 
quired on  the  part  of  the  practitioner 
as  to  which  blade  should  be  introduced 
uppermost — an  advantage  of  no  great 
value,  since  no  one  should  undertake  a 
case  of  forceps  delivery  who  has  not 
sufficient  knowledge  of  the  operation,  and  presence  of  mind  enough, 
to  obviate  any  risk  from  the  introduction  of  the  wrong  blade  first. 
On  account  of  its  shortness,  and  the  want  of  the  second  or  pelvic 
curve,  it  is  only  adapted  for  cases  in  which  the'  head  is  low  down  in 
the  pelvis,  or  actually  resting  on  the  perineum. 

The  Pelvic  Curve,  its  Advantages. — The  question  of  the  second  or 
pelvic  curve  is  one  on  which  there  is  much  difference  of  opinion.1 
The  forceps  we  are  now  considering,  and  the  many  modifications 
formed  on  the  same  plan,  is  constructed  solely  with  reference  to  its 
grasp  on  the  child's  head,  and  without  regard  to  the  axes  of  the 
maternal  passages.  Consequently  were  we  to  introduce  it  when  the 
head  was  at  the  upper  part  of  the  pelvis,  we  could  not  fail  to  expose 
the  soft  parts  to  the  risk  of  contusion,  and  (in  consequence  of  the 
necessity  of  drawing  more  directly  backwards)  unduly  stretch  and 
even  lacerate  the  perineum.  Hence  it  is  now  admitted  by  obstetri- 

['  The  credit  of  devising  the  pelvic  curve  is  now  given  to  Dr.  Benjamin  Pugh,  of 
Chelmsford,  Essex,  England,  1736.  Levret,  in  1747,  and  Smellie,  in  1751,  both 
used  it.  They  are  thought  to  have  acted  independently  in  the  invention... — ED.} 


Denman's  Short  Forceps. 


460 


OBSTETRIC    OPERATIONS. 


FlG.  151. 


cians,  with  few  exceptions,  that  the  second  curve  is  essential  before 
the  complete  descent  of  the  head,  although  it  is  not  absolutely  so 
after  this  has  taken  place.  The  only  circumstances  under  which  a 
straight  blade  can  possess  any  superiority  are  in  certain  cases  of 
occipito-posterior  position,  in  which  it  is  found  necessary  to  rotate 
the  head  round  a  large  extent  of  the  pelvis,  when  the  circular  sweep 
of  a  strongly-curved  instrument  might  prove  injurious.  Such  cases, 
however,  are  of  rare  occurrence,  and  need  in  no  way  influence  the 
general  employment  of  the  pelvic  curve. 

Zeiyler's  Forceps. — The  short  forceps,  usually  employed  in  Scot- 
land, is  the  invention  of  the  late  Zeigler  (Fig.  151),1  and  is  useful 
from  the  facility  with  which  the  blades  may  be 
introduced  in  accurate  apposition  to  each  other,  a 
point  which  in  practice  is  of  no  little  value.  In 
general  size  and  appearance  it  closely  resembles 
Denman's  forceps,  but  the  fenestrum  of  the  lower 
blade  is  continued  down  to  the  handle.  In  intro- 
ducing, the  lower  blade  is  slipped  over  the  handle 
of  the  other  blade  already  in  situ,  and  thus  it  is 
guided  with  great  certainty  into  a  proper  position, 
locking  itself  as  it  passes  on.  This  instrument  has 
the  disadvantage  of  not  having  the  second  curve, 
but  the  facility  of  introduction  has  rendered  it  a 
great  favorite  with  many  who  have  been  in  the 
habit  of  employing  it. 

The  Long  Forceps. — For  cases  in  which  the  head 
is  not  on  the  perineum,  or  at  least  not  quite  low  in 
the  pelvis,  a  longer  instrument  is  essential.  To 
meet  this  indication  Smellie  invented  the  long 
forceps,  which,  like  the  shorter  instrument,  has 
been  very  variously  modified.  The  most  perfect  instrument  of  the 
kind  employed  in  this  country  is  that  known  as  Simpson's  forceps 
(Fig.  152),  which  combines  many  excellent  points  selected  from  the 
forceps  of  various  obstetricians,  as  well  as  some  original  additions, 
and  which,  as  a  whole,  has  never  been  surpassed.  The  curved  portions 
of  the  blades  are  6J  inches  long,  the  fenestrum  measuring  1^  at  its 
widest  part.  The  extremities  of  the  blades  are  1  inch  asunder  when 
the  handles  are  closed,  and  3  inches  at  their  widest  part.  The  object 
of  this  somewhat  unusual  width  is  to  lessen  the  compressing  power 
of  the  instrument,  without  in  any  way  interfering  with  its  action  as 
a  tractor.  The  pelvic  curve  is  less  than  in  most  long  forceps,  so  as 
to  admit  of  the  rotation  of  the  head  when  necessary,  without  the  risk 
of  injuring  the  maternal  structures.  Between  the  curve  of  the  blade 
and  the  lock  is  a  straight  portion  or  shank,  measuring  2f  inches, 
which,  before  joining  the  handle,  is  bent  at  right  angles  into  a  knee. 
This  shank  is  a  useful  addition  to  all  forceps,  and  is  essential  in  the 
long  forceps  to  insure  the  junction  of  the  blades  beyond  the  parts  of 
the  mother,  which  might  otherwise  be  caught  in  the  lock  and  injured. 


Zeigler's  Forceps. 


It  has  been  made  here,  but  is  not  regarded  with  any  favor. — En.] 


THE    FORCEPS. 


4(31 


The  knees  serve  the  purpose  of  preventing  the  blades  from  slipping 
from  each  other  after  they  have  been  united.  They  also  admit  of 
one  finger  being  introduced  above  the  lock,  and  used  as  an  aid  in 
traction;  a  provision  which  is  made  in  some  other  varieties  of  long 
forceps  by  a  semicircular  bend  in 

each  shank.     The  handles  which  FIG.  152. 

in  most  British  forceps  are  too 
small  and  smooth  to  afford  a  firm 
grasp,  are  serrated  at  the  edge,  and 
flattened  from  before  backwards, 
so  as  to  fit  the  closed  fist  more 
accurately.  At  their  extremities, 
near  the  lock,  there  are  a  pair  of 
projecting  rests,  over  which  the 
fore  arid  middle  fingers  may  be 
passed  in  traction,  and  which 
greatly  increase  our  power  over 
the  instrument.  Although  this, 
and  other  varieties  of  the  long 
forceps,  are  specially  constructed 
for  application  when  the  head  is 
high  in  the  pelvis,  it  answers  quite 
as  well  as  the  short  forceps — in- 
deed, in  most  respects  better — 
when  the  head  has  descended  low 
down.  It  is  a  decided  advantage 
for  the  practitioner  to  habituate 
himself  to  the  use  of  one  instru- 
ment, with  the  application  and 

power     of     which     he     becomes  ^H  H|  |  0 

thoroughly  familiar.  It  is  a  mere 
waste  of  space  and  money  for  him  Simpson's  Forceps, 

to  incumber  himself  with  a  num- 
ber of  instruments  of  various  shapes  and  sizes,  and  he  may  be  sure 
that  a  good  pair  of  long  forceps,  such  as  Simpson's,  will  be  suitable 
for  every  emergency,  and  in  any  position  of  the  head. 

Disadvantages  of  a  Weak  Instrument. — The  chief  argument  against 
the  use  of  such  an  instrument  in  simple  cases  is  its  great  power. 
This,  however^  is  entirely  based  on  a  misconception.  The  existence 
of  power  does  not  involve  its  use,  and  the  stronger  instrument  can 
be  employed  with  quite  as  much  delicacy  and  gentleness  as  the 
weaker.  The  remarks  of  Dr.  Hodge1  on  this  point  are  extremely 
apposite,  and  are  well  worthy  of  quotation.  He  says,  "  Certainly  no 
man  ought  to  apply  the  forceps  who  has  not  sufficient  discretion  to 
use  no  more  force  than  is  absolutely  requisite  for  safe  delivery  ;  if, 
therefore,  there  is  more  power  at  command,  he  is  not  obliged  to  use  it; 
while,  on  the  contrary,  if  much  power  be  demanded,  he  can,  within 
the  bounds  of  prudence,  exercise  it  by  the  long  forceps,  but  with  the 


System  of  Obstetrics,  p.  242. 


462 


OBSTETRIC    OPERATIONS. 


FlG.   153. 


short  forceps  his  efforts  might  be  unavailing;  moreover,  in  cases  of 
difficulty,  the  short  forceps  being  used,  the  practitioner  would  be 
forced  to  make  great  muscular  efforts ;  while  with  the  long  forceps, 
owing  to  the  great  leverage,  such  effort  will  be  comparatively  trifling. 
and,  of  course  the  whole  force  demanded  can  be  much  more  deli- 
cately, and  at  the  same  time  efficiently,  applied,  and  with  more  safety 
to  the  tissues  of  the  child  and  its  parent." 

Continental  Forceps. — The  forceps  usually  employed  on  the  Con- 
tinent, and  in  America,  differ  considerably,  both  in  appearance  and 
construction,  from  those  in  use  in  this  country.  As  a  rule  it  is  a 
larger  and  more  powerful  instrument,  joined  by  a  pivot  or  button 
joint,  and  it  always  possesses  the  second  or  pelvic  curve.  Of  late 
years  Simpson's  forceps  has  been  much  employed  in  some  parts 

of  Germany.  The  chief  objection  to 
the  Continental  instruments  is  their 
cumbrousness.  This  is  chiefly  in  the 
handles,  which  in  many  of  them  are 
forged  in  a  piece  with  the  blades,  the 
part  introduced  within  the  maternal 
structures  not  being  materially  differ- 
ent from  the  corresponding  part  of  the 
English  instrument. 

The  forceps  invented  by  Professor 
Tarnier  (Fig.  153)  have  recently  at- 
tracted considerable  attention.  In  this 
instrument  traction  is  not  made  on  the 
handles  by  which  the  blades  are  intro- 
duced, as  in  ordinary  forceps,  but  on  a 
supplementary  handle  (a)  subsequently 
attached  to  the  blades  near  the  lower 
opening  of  their  fenestra  (ft).  The 
object  claimed  for  this  arrangement  is 
that  less  force  is  required  in  traction, 
which  can  always  be  made  in  the 

proper  axis  of  the  pelvis ;  that  the  blades  are  not  likely  to  slip ;  and 
that  rotation  of  the  head  is  not  interfered  with.  The  instrument, 
however,  is  much  more  complex  than  that  usually  employed  in  this 
country,  and  does  not  seem  to  possess  sufficient  advantages  to  coun- 
terbalance this  defect.  [Professor  Tarnier  has  adopted,  in  this  in- 
strument, the  blades  of  Davis.  It  has  been  much  simplified  recently, 
by  Dr.  Eichard  A.  Cleemann,  of  Philadelphia,  by  taking  away  the 
long  curve  of  the  handles,  dispensing  with  the  tongue,  and  bending 
forward  the  shanks. — ED.] 

Action  of  the  Instrument. — The  forceps  is  generally  said  to  act  in 
three  different  ways  : — 
1st.  As  a  tractor. 
2d.  As  a  lever. 
3d.  As  a  compressor. 

The  Chief  Use  of  the  Forceps  as  a  Tractor. — It  is  more  especially  as 
a  tractor  that  the  instrument  is  of  value,  and  it  is  used  with  the  great- 


Tarnier's  Forceps. 


THE    FORCEPS.  463 

est  advantage  when  it  is  employed  merely  to  supplement  the  action 
of  the  uterus,  which  is  insufficient  of  itself  to  effect  delivery,  or  when, 
from  some  complication,  it  is  necessary  to  complete  labor  with  greater 
rapidity  than  can  be  accomplished  by  the  unaided  powers  of  nature. 
In  most  cases  traction  alone  is  sufficient ;  but,  in  order  that  it  may 
act  satisfactorily,  and  that  the  instrument  may  not  slip,  a  proper  con- 
struction of  the  forceps,  and  a  sufficient  curvature  of  the  blades,  are 
essential.  The  want  of  these  is  the  radical  fault  of  many  of  the 
short,  straight  instruments  in  common  use,  which  have  a  tendency  to 
slip  during  our  efforts  at  extraction. 

As  a  Lever. — The  forceps  acts  also  as  a  lever,  but  this  action  has 
been  greatly  exaggerated.  It  is  generally  described  as  a  lever  of  the 
first  class,  the  power  being  at  the  handles,  the  fulcrum  at  the  lock, 
and  the  weight  at  the  extremities.  There  may  possibly  be  some 
leverage  power  of  this  kind  when  the  instrument  is  first  introduced, 
and  the  handles  held  so  loosely  that  one  blade  is  able  to  work  on  the 
other.  But,  as  ordinarily  used,  the  handles  are  held  with  a  suffi- 
ciently firm  grasp  to  prevent  this  movement,  and  then  the  two  blades 
practically  form  a  single  instrument. 

Galabin,  who  has  studied  this  subject  in  detail,  points  out1  that : 
"  1.  The  lever  is  formed  by  both  blades  of  the  forceps  and  the  foetal 
head  united  in  one  immovable  mass.  As  soon  as  the  blades  begin 
to  slip  over  the  head,  the  lever  is  decomposed,  and  the  swaying  move- 
ment ceases  to  have  any  mechanical  advantage.  2.  The  power  is 
applied  to  the  handles  in  a  slanting  direction.  The  resistance  or 
weight  does  not  act  at  a  point  either  between  the  former  and  the 
fulcrum,  or  beyond  the  fulcrum,  but  at  a  point  in  a  plane  nearly  at 
right  angles  to  the  line  joining  these  two  points ;  and  its  direction  is 
a  line  perpendicular  to  that  plane  of  the  pelvis  in  which  the  greatest 
section  of  the  head  is  engaged,  that  is  to  say,  in  the  case  of  straight 
forceps,  nearly  parallel  to  the  handles.  The  lever  formed  does  not, 
therefore,  strictly  speaking,  belong  to  any  one  of  the  three  orders 
into  which  levers  are  commonly  divided.  3.  The  fulcrum  is  fixed 
partly  by  friction,  partly  by  the  combination  of  traction  with  oscil- 
latory movement — in  other  words,  by  the  power  being  directed  in 
great  measure  downwards,  and  only  slightly  to  one  side." 

He  further  shows  that  the  pendulum  motion  of  the  forceps  is  super- 
fluous in  all  ordinary  forceps  operations,  in  which  traction  alone  is 
amply  sufficient  for  delivery ;  but  that  when  the  head  is  impacted, 
and  great  force  is  required  for  its  extraction,  a  mechanical  advantage 
may  be  gained  from  having  recourse  to  an  oscillatory  movement, 
which  should,  however,  be  very  limited,  and  only  continued  if  found 
to  effect  distinct  advance  of  the  head. 

As  a  Compressor. — Regarding  the  compressive  power  of  the  instru- 
ment there  has  been  much  difference  of  opinion.  There  is  no  doubt 
'that  the  forceps,  especially  some  of  the  foreign  instruments  in  which 
the  points  nearly  approach  each  other,  is  capable  of  exerting  con- 

1  Galabin,  "Action  of  Midwifery  Forceps  as  a  Lever,"  Obstetrical  Journal, 
November,  1876. 


464  OBSTETRIC  OPERATIONS. 

siderable  compression  on  the  head.  It  is,  however,  extremely  prob- 
lematical if  this  action  be  of  real  value.  It  is  to  be  borne  in  mind 
that  in  cases  of  protracted  labor  the  head  has  been  already  moulded 
and  compressed,  and  the  bones  have  been  made  to  overlap  each  other 
to  their  utmost  extent,  by  the  sides  of  the  pelvis ;  we  can  scarcely, 
therefore,  expect  to  diminish  the  head  much  more  by  the  forceps, 
without  employing  an  amount  of  force  that  will  seriously  endanger 
the  life  of  the  child.  It  is  in  cases  of  disproportion  between  the 
head  and  the  pelvis,  depending  on  slight  autero-posterior  contraction 
of  the  pelvic  brim,  that  diminution  of  the  child's  head  by  compres- 
sion would  be  most  useful.  Then,  however,  the  pressure  of  the 
forceps  is  exerted  on  that  portion  of  the  head  which  lies  in  the  most 
roomy  diameter  of  the  pelvis,  where  there  is  no  want  of  space.  If 
this  pressure  do  not  increase  the  opposite  diameter,  which  is  in  appo- 
sition to  the  narrower  portion  of  the  pelvis,  it  can  at  least  do  nothing 
towards  lessening  it ;  and  diminution  of  any  other  part  of  the  child's 
head  is  not  required. 

Dynamical  Action  of  the  Forceps. — The  mere  introduction  of  the 
forceps  sometimes  excites  increased  uterine  action,  through  the  reflex 
irritation  induced  by  the  presence  of  a  foreign  body  in  the  vagina. 
This  has  been  called  the  dynamical  action  of  the  forceps ;  but  it  can- 
not be  looked  upon  in  any  other  light  than  that  of  an  occasional 
accidental  result. 

The  circumstances  indicating  the  use  of  the  forceps  have  been 
separately  considered  elsewhere,  and  to  recapitulate  them  here  would 
only  lead  to  needless  repetition.  I  shall  therefore  now  merely  de- 
scribe the  mode  of  using  the  instrument. 

Difference  between  the  High  and  Low  Operations. — Before  doing  so 
it  is  well  to  repeat  what  has  already  been  said  as  to  the  difference 
between  what  may  be  termed  the  high  and  low  forceps  operations. 
The  application  of  the  instrument,  when  the  head  is  low  in  the  pelvis, 
is  extremely  simple;  and  when  there  is  110  disproportion  between  the 
head  and  the  pelvis,  and  some  slight  traction  is  alone  required  to 
supplement  deficient  expulsive  power,  the  operation,  in  the  hands  of 
any  ordinarily  well-instructed  practitioner,  ought  to  be  perfectly  safe 
both  to  the  mother  and  child.  It  is  very  different  when  the  head  is 
arrested  at  the  brim,  or  high  in  the  pelvis.  Then  the  application  of 
the  forceps  is  an  operation  requiring  much  dexterity  for  its  proper 
performance,  and  must  never  be  undertaken  without  anxious  con- 
sideration. It  is  because  these  two  classes  of  operations  have  been 
confused  that  the  use  of  the  instrument  is  regarded  by  many  with 
such  unreasonable  dread. 

Preliminary  Considerations. — Before  attempting  to  introduce  the 
forceps,  there  are  several  points  to  which  attention  should  be  di- 
rected : — 

1st.  The  membranes  must,  of  course,  be  ruptured. 

2dly.  For  the  safe  and  easy  application  of  the  instrument,  it  is 
also  advisable  that  the  os  should  be  fully  dilated,  and  the  cervix  re- 
tracted over  the  head.  Still,  these  two  points  cannot  be  regarded,  as 
many  have  laid  down,  as  being  sine  qua  non.  Indeed  we  are  often 


THE    FORCEPS.  465 

compelled  to  use  the  instrument  when,  although  the  os  is  fully  dilated, 
the  rim  of  the  cervix  can  be  felt  at  some  point  of  the  contour  of  the 
head,  especially  in  cases  in  which  the  anterior  lip  is  jammed  between 
the  head  and  the  pubis.  Provided  due  care  be  taken  to  guard  the 
cervical  rim  with  the  ringers  of  one  hand,  as  the  instrument  is 
slipped  past  it,  there  need  be  no  fear  of  injury  from  this  cause.  If 
the  os  be  not  fully  dilated,  but  is  sufficiently  open  to  admit  of  the 
passage  of  the  forceps,  the  operation,  under  urgent  circumstances, 
may  be  quite  justifiable,  but  it  must  necessarily  be  a  somewhat 
anxious  one. 

3dly.  The  position  of  the  head  should  be  accurately  ascertained 
by  means  of  the  sutures  and  fontanelles.  Unless  this  be  done,  the 
operation  will  always  be  hap-hazard  and  unsatisfactory,  as  the  prac- 
titioner can  never  be  in  possession  of  accurate  knowledge  of  the  pro- 
gress of  the  case.  It  may  be  that  the  occiput  is  directed  backwards ; 
and,  although  that  does  not  centra-indicate  the  application  of  the 
forceps,  it  involves  special  precautions  being  taken. 

4thly.  The  bladder  and  bowels  should  be  emptied. 

Question  of  Administering  Ansesthetics. — Before  proceeding  to  ope- 
rate, the  question  of  anaesthesia  will  arise.  In  any  case  likely  to  be 
difficult  it  is  of  the  greatest  assistance  to  have  the  patient  completely 
under  the  influence  of  an  anaesthetic  to  the  surgical  degree,  so  as  to 
have  her  as  still  as  possible;  but,  whenever  this  is  deemed  necessary, 
another  practitioner  should  undertake  the  responsibility  of  the  admin- 
istration. In  simple  cases  I, believe  it  is  better  to  dispense  with  anaes- 
thetics altogether,  partly  because  they  are  apt  to  stop  what  pains 
there  are,  which  is  in  itself  a  disadvantage,  but  chiefly  because,  under 
partial  anaesthesia,  the  patient  loses  her  self-control,  is  restless,  and 
twists  herself  into  awkward  positions,  which  give  rise  to  the  utmost 
difficulty  and  inconvenience  in  the  use  of  the  instrument.  Moreover, 
if  no  anaesthetic  be  given,  the  patient  can  assist  the  operator  by 
placing  herself  in  the  most  convenient  attitude. 

Description  of  the  Operation. — In  describing  the  method  of  apply- 
ing the  forceps,  I  shall  assume  that  we  have  to  do  with  the  simpler 
variety  of  the  operation,  when  the  head  is  low  in  the  pelvis.  Sub- 
sequently I  shall  point  out  the  peculiarities  of  the  high  operation. 

Position  of  the  Patient. — As  to  the  position  of  the  patient,  I  believe 
there  can  be  no  doubt  of  the  superiority  of  that  which  is  usually 
adopted  in  this  country.  On  the  Continent  and  in  America  the  for- 
ceps is  always  employed  with  the  patient  lying  on  her  back,  a  posi- 
tion involving  much  needless  exposure  of  the  person,  and  requiring 
more  assistance  from  others.  In  certain  cases  of  unusual  difficulty 
the  position  on  the  back  is  of  unquestionable  utility,  but  we  may,  at 
least,  commence  the  operation  in  the  usual  way,  and  subsequently 
turn  the  patient  on  her  back  if  desirable. 

Importance  of  a  /Suitable  Position. — Much  of  the  facility  with  which 
the  blades  are  introduced  depends  on  the  patient's  being  properly 
placed.  Hence,  although  it  gives  rise  to  a  little  more  trouble  at  first, 
I  believe  that  it  is  always  best  to  pay  particular  attention  to  this 
point,  whether  the  high  or  low  forceps  operation  be  about  to  be  per- 


460 


OBSTETRIC    OPERATIONS, 


formed.  The  patient  should  be  brought  quite  to  the  side  of  the  bed, 
with  her  nates  parallel  to,  and  projecting  somewhat  over  its  edge. 
The  body  should  lie  almost  directly  across  the  bed,  and  nearly  at 
right  angles  to  the  hips,  with  the  knees  raised  towards  the  abdomen 


FIG.  154. 


Position  of  Patient  for  Forceps  Delivery  and  Mode  of  Introducing  Lower  Bl^de. 

(Fig.  154).  In  this  way  there  is  no  risk  of  the  handle  of  the  upper 
blade,  when  depressed  in  introduction,  coming  in  contact  with  the 
bed. 

The  blades  should  be  warmed  in  tepid  water,  lubricated  with  cold 
cream  or  carbolic  oil,  and  placed  ready  to  hand. 

These  preliminaries  having  been  attended  to,  we  proceed  to  the  in- 
troduction of  the  blades,  sitting  by  the  side  of  the  bed,  opposite  the 
nates  of  the  patient. 

Direction  in  which  the  Blades  are  to  be  Introduced. — The  important 
question  now  arises,  in  what  direction  are  the  blades  to  be  passed? 
The  almost  universal  rule  in  our  standard  works  is,  that  they  mast 
be  passed  as  nearly  as  possible  over  the  child's  ears,  without  any  re- 
ference to  the  pelvic  diameters.  Hence,  if  the  head  have  not  made 
its  turn,  but  is  lying  in  one  oblique  diameter,  the  blades  would  re- 
quire to  be  passed  in  the  opposite  oblique  diameter ;  in  short,  the 
position  of  the  forceps,  as  regards  the  pelvis,  must  vary  according 
to  the  position  of  the  head.  Some  have  even  laid  down  the  rule, 
that  the  forceps  is  contra-indicated  unless  an  ear  can  be  felt ;  a  rule 
that  would  very  seriously  limit  its  application,  as  in  many  cases  in 
which  it  is  urgently  required  it  is  a  matter  of  great  difficulty,  and 
even  impossibility,  to  feel  the  ear  at  all.  [This  is  not  the  practice  in 
this  country  with  those  who  use  the  forceps  of  Hodge,  Wallace,  or 
Davis,  which  are  designed  to  be  applied  over  the  parietal  protuber- 
ances whenever  practicable. — ED.]  It  is  admitted  that  in  the  high 


THE    FORCEPS.  467 

forceps  operation  the  blades  must  be  introduced  in  tlie  transverse 
diameter  of  the  pelvis,  without  relation  to  the  position  of  the  head. 
On  the  Continent  it  is  generally  recommended  that  this  rule  should 
be  applied  to  all  cases  of  forceps  delivery  alike,  whether  the  head  be 
high  or  low,  and  I  have  now  for  many  years  adopted  this  plan,  and 
passed  the  blades  in  all  cases,  whatever  be  the  position  of  the  head, 
in  the  transverse  diameter  of  the  pelvis,  without  any  attempt  to  pass 
them  over  the  bi-parietal  diameter  of  the  child's  head.  Dr.  Barnes 
points  out  with  great  force  that,  do  what  we  will,  and  attempt  as  we 
may,  to  pass  the  blades  in  relation  to  the  child's  head,  they  find  their 
way  to  the  sides  of  the  pelvis,  and  that  the  marks  of  the  fenestra  on 
the  head  always  show  that  it  has  been  grasped  by  the  brow  and  side 
of  the  occiput.  [That  is  because  the  variety  of  forceps  used  does 
not  conform  to  the  contour  of  the  head. — ED.]  Of  the  perfect  cor- 
rectness of  this  observation  I  have  no  doubt ;  hence  it  is  a  needless 
element  of  complexity  to  endeavor  to  vary  the  position  of  the  blades 
in  each  case,  and  one  which  only  confuses  the  inexperienced  practi- 
tioner, and  renders  more  difficult  an  operation  which  should  be  sim- 
plified as  much  as  possible.  While,  therefore,  it  is  of  importance 
that  the  precise  position  of  the  head  should  be  ascertained  in  order 
that  we  may  have  an  intelligent  notion  of  its  progress,  I  do  not 
think  that  it  is  essential  as  a  guide  to  the  introduction  of  the 
forceps. 

Method  of  Introducing  the  Lower  Blade. — 'As  a  rule  the  lower  blade, 
lightly  grasped  between  the  tips  of  the  index  and  middle  fingers  and 
thumb,  should  be  introduced  first.  Poised  in  this  way,  we  have  per- 
fect command  over  it,  and  can  appreciate  in  a  moment  any  obstacle 
to  its  passage.  Two  or  more  fingers  of  the  left  hand  are  introduced 
into  the  vagina,  and  by  the  side  of  the  head,  as  a  guide ;  the  greatest 
care  must  be  taken,  if  the  cervix  be  within  reach,  that  they  are 
passed  within  it,  so  as  to  avoid  the  possibility  of  injury. 

Necessity  of  Gentleness  in  Passing  the  Instrument. — The  handle  of 
the  instrument  has  to  be  elevated,  and  its  point  slid  gently  along  the 
palmar  surface  of  the  guiding  fingers,  until  it  touches  the  head  (Fig. 
154).  At  first  the  blade  should  be  inserted  in  the  axis  of  the  outlet, 
but,  as  it  progresses,  the  handle  must  be  depressed  and  carried  back- 
wards. As  it  is  pushed  onwards  it  is  made  to  progress  by  a  slight 
side-to-side  motion,  and  it  is  of  the  utmost  importance  to  bear  in 
mind  that  the  greatest  gentleness  must  always  be  used.  If  any  ob- 
struction be  felt,  we  are  bound  to  withdraw  -the  instrument,  partially 
or  entirely,  and  attempt  to  manoeuvre,  not  force,  the  point  past  it. 
As  the  blade  is  guided  on  in  this  way,  it  is  made  to  pass  over  the  con- 
vexity of  the  head,  the  point  being  always  kept  lightly  in  contact 
with  it,  until  it  finally  gains  its  proper  position.  When  fully  inserted 
the  handle  is  drawn  back  towards  the  perineum,  and  given  in  charge 
to  an  assistant.  The  insertion  must  be  carried  on  only  in  the  inter- 
vals between  the  pains,  and  desisted  from  during  their  occurrence ; 
otherwise  there  would  be  a  serious  risk  of  injuring  the  soft  parts  of 
the  mother. 


468 


OBSTETRIC    OPERATIONS, 


Introduction  of  the  Upper  Blade. — The  second  blade  is  passed  di- 
rectly opposite  to  the  first,  and  is  generally  somewhat  more  difficult 
to  introduce,  in  consequence  of  the  space  occupied  by  the  latter.  It 
is  passed  along  two  lingers  directly  opposite  the  first  blade,  and  with 
exactly  the  same  precautions  as  to  direction  and  introduction,  except 
that  at  first  its  handle  has  to  be  depressed  instead  of  elevated  (Fig. 
155). 

FIG.  155. 


Introduction  of  the  Upper  Blade. 

Locking  of  the  Handles. — The  handle  which  was  in  charge  of  the 
assistant  is  now  laid  hold  of  by  the  operator,  and  the  two  handles 
are  drawn  together.  If  the  blades  have  been  properly  introduced, 
there  should  be  no  difficulty  in  locking ;  but,  should  we  be  unable  to 
join  them  easily,  we  must  withdraw  one  or  other,  either  partially  or 
entirely,  and  reintroduce  it  with  the  same  precautions  as  before.  We 
must  also  assure  ourselves  that  no  hairs,  nor  any  of  the  maternal 
structures  are  caught  in  the  lock. 

Method  of  Tractions — When  once  the  blades  are  locked  we  may 
commence  our  efforts  at  traction.  To  do  this  we  lay  hold  of  the 
handles  with  the  right  hand,  using  only  sufficient  compression  to 
give  a  firm  grasp  of  the  head,  and  to  keep  the  blades  from  slipping. 
The  left  hand  may  be  advantageously  used  in  assisting  and  support- 
ing the  right  during  our  efforts  at  extraction,  and,  at  a  late  stage  of 
the  operation,  may  be  employed  in  relaxing  the  perineum  when 
stretched  by  the  head  of  the  child.  Traction  must  always  be  made 
in  reference  to  the  pelvic  axes;  being  at  first  backwards  towards  the 
perineum  (Fig.  156),  in  the  direction  of  the  axis  of  the  brim,  and  as 
the  head  descends  and  the  vertex  protrudes  through  the  vulva,  it 
must  be  changed  to  that  of  the  outlet.  We  must  extract  only  during 
the  pains;  and,  if  these  should  be  absent,  we  must  imitate  them  by 


THE    FORCEPS. 


400 


acting  at  intervals.  This  is  a  point  which  deserves  special  attention, 
for  there  is  no  more  common  error  than  undue  hurry  in  delivery. 
The  only  valid  objection  I  know  of  against  a  more  frequent  resort 
to  the  forceps  in  lingering  labors  is,  that  the  sudden  emptying  of  the 


FIG.  156. 


Forceps  in  Position.     Traction  in  the  Axis  of  the  Brim,  downwards  and  backwards. 

uterus,  in  the  absence  of  pains,  may  predispose  to  hemorrhage;  and 
it  cannot  be  denied  that  it  is  one  of  some  weight.  However,  if  due 
care  be  taken  to  operate  slowly,  and  to  allow  several  minutes  to 
elapse  between  each  tractive  effort,  while,  at  the  same  time,  uterine 
contractions  be  stimulated  by  pressure  and  support,  this  need  not  be 
considered  a  contra-indication.  Besides  direct  traction  we  may  im- 
part to  the  instrument  a  gentle  waving  motion  from  handle  to  handle, 
which  brings  into  operation  its  power  as  a  lever;  but  this  must  not 
be  done  to  any  great  extent,  and  must  always  be  subservient  to  direct 
traction. 

Descent  of  the  Head. — Proceeding  thus  in  a  slow  and  cautious 
manner,  carefully  regulating  the  force  employed  according  to  the 
exigencies  of  the  case,  we  shall  perceive  that  the  head  begins  to 
descend ;  and  its  progress  should  be  determined,  from  time  to  time, 
by  the  fingers  of  the  unemployed  hand. 

The  Rotation  from  the  Oblique  Diameter. — When  the  head  lies  in 
the  oblique  diameter,  as  it  descends,  in  consequence  of  its  perfect 
adaptation  to  the  pelvic  cavity,  it  will  turn  into  the  antero-posterior 
diameter  without  any  effort  on  the  part  of  the  operator,  provided 
only  that  the  traction  be  sufficiently  slow  and  gradual.  As  the  head 
is  about  to  emerge,  it  is  necessary  to  raise  the  handles  towards  the 
mother's  abdomen.  More  than  usual  care  is  required  to  prevent 


470 


OBSTETRIC    OPERATIONS. 


laceration  of  the  perineum,  which  is  always  much  stretched  (Fig. 
157).  If,  as  often  happens,  the  pains  have  now  increased,  and  the 
perineum  be  very  thin  and  tense,  it  may  even  be  desirable  to  remove 
the  blades  gently,  and  leave  the  case  to  be  terminated  by  the  natural 
powers ;  but  if  due  precautions  are  used  this  need  not  be  necessary. 


FIG.  157. 


Last  Stage  of  Extraction.    The  Handles  of  the  Forceps  turned  upwards  towards  the  Mother's 

Abdomen. 

The  peculiarities  of  forceps  delivery  in  occipito-posterior  positions 
have  already  been  discussed  (p.  307),  and  need  not  be  repeated. 

Hifjh  Forceps  Operations. — When  the  high  forceps  operation  has 
been  decided  on,  the  passage  of  the  blades  will  be  found  to  be  much 
more  difficult  from  the  height  of  the  presenting  part,  the  distance 
which  they  must  pass,  and,  in  some  cases,  from  the  mobility  of  the 
head  interfering  with  their  accurate  adaptation.  The  general  prin- 
ciples of  introduction  and  of  traction  are,  however,  identical.  If  the 
operation  be  attempted  before  the  head  has  entered  the  pelvic  brim, 
it  must  be  fixed,  as  much  as  possible,  by  abdominal  pressure.  In 
guiding  the  blades  to  the  head  special  care  must  be  taken  to  avoid 
any  injury  of  the  soft  parts,  especially  if  the  cervix  be  not  com- 
pletely out  of  reach.  For  this  purpose  it  may  even  be  advisable  to 
introduce  the  entire  left  hand  as  a  guide,  so  as  to  avoid  any  possi- 
bility of  injuring  the  cervix,  from  not  passing  the  instrument  under 
its  e'dge. 

Peculiar  Method  of  Introducing  the  Blades. — Some  authors  advise 
that,  in  such  cases,  the  blade  should  be  introduced  at  first  opposite 


THE    FORCEPS.  471 

the  sacrum,  until  the  point  approaches  its  promontory.  It  is  then 
made  to  sweep  round  the  pelvis,  under  the  protecting  fingers,  till  it 
reaches  its  proper  position  on  the  head.  This  plan  is  advocated  by 
Eamsbotharn,  Hall  Davis,  and  other  eminent  practical  accoucheurs, 
and  it  is  certainly  of  service  in  some  cases  of  difficulty ;  especially 
when,  from  any  reason,  it  is  not  possible  to  draw  the  nates  over  the 
edge  of  the  bed,  when  the  necessary  depression  of  the  handle  of  the 
upper  blade  is  difficult  to  effect.  It  involves,  however,  a  somewhat 
complicated  manoeuvre,  and  it  is  seldom  that  the  blades  cannot  be 
readily  introduced  in  the  usual  way. 

Necessity  of  Care  in  Locking. — In  locking  the  slightest  approach 
to  roughness  must  be  carefully  avoided,  for  the  extremities  of  the 
blades  are  now  within  the  cavity  of  the  uterus,  and  serious  injury 
might  easily  be  inflicted.  If  difficulty  be  met  with,  rather  than  em- 
ploy any  force,  one  of  the  blades  should  be  withdrawn,  and  reintro- 
duced  in  a  more  favorable  direction.  If  the  blades  have  shanks  of 
sufficient  length,  there  should  be  no  risk  of  including  the  soft  parts 
of  the  mother  in  the  lock,  which,  in  a  badly  constructed  instrument, 
is  an  accident  not  unlikely  to  occur. 

Method  of  Traction. — After  junction  traction  must  at  first  be  alto- 
gether in  the  axis  of  the  brim,  and  to  effect  this  the  handles  must  be 
pressed  well  backwards  towards  the  perineum.  As  the  head  descends 
it  will  probably  take  the  usual  turn  of  itself,  without  effort  on  the 
part  of  the  operator,  and  the  direction  of  the  tractive  force  may  be 
gradually  altered  to  that  of  the.  axis  of  the  outlet. 

If  the  pains  be  strong  and  regular,  and  there  be  no  indication  for 
immediate  delivery,  we  may  remove  the  forceps  after  the  head  has 
descended  upon  the  perineum,  and  leave  the  conclusion  of  the  case 
to  nature.  This  course  may  be  especially  advisable  if  the  perineum 
and  soft  parts  be  unusually  rigid ;  but  generally  it  is  better  to  termi- 
nate labor  without  removing  the  instrument. 

Possible  Dangers  of  forceps  Delivery. — Before  concluding  this  sub- 
ject, reference  may  be  made  to  the  possible  dangers  of  the  operation. 
I  would  here  again  insist  on  the  importance  of  distinguishing  be- 
tween the  high  and  low  forceps  operations,  which  have  been  so  unfor- 
tunately and  unfairly  confounded.  Eeasons  have  already  been  given 
for  rejecting  the  statistics  of  the  risks  attending  forceps  delivery  in 
the  latter  class  of  cases  (p.  335).  A  formidable  catalogue  of  dangers, 
both  to  the  mother  and  child,  might  easily  be  gathered  from  our 
standard  works  on  obstetrics.  Among  the  former  the  principal  are 
lacerations  of  the  uterus,  vagina,  and  perineum  ;  rupture  of  varicose 
veins,  giving  rise  to  thrombus ;  pelvic  abscess,  from  contusion  of  the 
soft  parts;  subsequent  inflammation  of  the  uterus  or  peritoneum; 
tearing  asunder  of  the  joints  and  symphyses;  and  even  fracture  of 
the  pelvic  bones.  A  careful  analysis  of  these,  such  as  has  been  so 
well  made  by  Drs.  Hicks  and  Philips,1  proves  beyond  doubt  that  the 
application  of  the  instrument  is  not  so  much  concerned  in  their  pro- 
duction, as  the  protraction  of  the  labor,  and  the  neglect  of  the  practi- 

1  Obst.  Trans.,  vol.  xiii. 


472  OBSTETRIC  OPERATIONS. 

tioner  in  not  interfering  sufficiently  soon  to  prevent  the  occurrence 
of  the  evil  consequences  afterwards  attributed  to  the  operation  itself. 
Many  of  these  will  be  found  to  arise  from  the  prolonged  pressure  on 
the  soft  parts  within  the  pelvis,  and  the  subsequent  inflammation  or 
sloughing.  To  these  causes  may  be  referred  with  propriety  most 
cases  of  vesico- vaginal  fistula  (p.  427),  peritonitis,  and  metritis  fol- 
lowing instrumental  labor. 

Lacerations  and  similar  accidents  may,  however,  result  from  an 
incautious  use  of  the  instrument.  Slight  lacerations  of  the  mucous 
membrane  of  the  vagina  are  probably  far  from  uncommon.  But  if 
these  cases  were  closely  examined,  it  would  be  found  that  the  fault 
lay  not  in  the  instrument,  but  in  the  hand  that  used  it.  Either  the 
blades  were  introduced  without  due  regard  to  the  axes  of  the  pelvis, 
or  they  were  pushed  forwards  with  force  and  violence,  or  an  instru- 
ment was  employed  unsuitable  to  the  case  (such  as  a  short  straight 
forceps  when  the  head  was  high  in  the  pelvis),  or  undue  haste  and 
force  in  'delivery  were  used.  It  would  be  manifestly  unfair  to  lay 
the  blame  of  such  results  upon  the  forceps,  which,  in  the  hands  of  a 
more  judicious  and  experienced  practitioner,  would  have  effected  the 
desired  object  with  perfect  safety.  The  instrument  is  doubtless 
unsafe  in  the  hands  of  any  one  who  does  not  understand  its  use,  just 
as  the  scalpel  or  amputating  knife  would  be  in  the  hands  of  a  rash 
and  inexperienced  surgeon.  The  lesson  to  be  learnt  seems  to  be 
clearly,  not  that  the  dangers  should  deter  us  from  the  use  of  the 
forceps,  but  that  they  should  induce  us  to  study  more  carefully  the 
cases  in  which  it  is  applicable,  and  the  method  of  using  it  with 
safety. 

Possible  Risks  to  the  Child. — The  dangers  to  the  child  are  princi- 
pally, lacerations  of  the  integuments  of  the  scalp  and  forehead ;  con- 
tusion of  the  face  ;  partial,  but  temporary,  paralysis  of  the  face  from 
pressure  of  a  blade  on  the  facial  nerve ;  depression  or  fracture  of  the 
cranial  bones ;  injury  to  the  brain  from  undue  pressure  of  the  blades. 
These  evils  are  of  rare  occurrence,  and  when  they  do  happen,  gene- 
rally result  from  improper  management  of  the  operation — such  as 
undue  compression,  the  use  of  improper  instruments,  or  excessive 
and  ill-directed  efforts  at  traction — and  cannot,  therefore,  be  con- 
sidered as  in  any  way  contra-indicating  the  use  of  the  instrument. 
Many  of  the  more  common  results,  such  as  slight  abrasions  of  the 
scalp,  or  paralysis  of  the  face,  are  transitory  in  their  nature  and  of 
no  real  consequence. 

[Although  obstetrical  forceps  were  first  used  in  England,  other 
countries  in  the  march  of  improvement  have  made  great  changes, 
not  only  in  the  original  forms,  but  in  their  manner  of  use ;  and  diffe- 
rent shapes,  as  well  as  different  positions  of  the  woman  in  application, 
have  become  in  a  measure  almost  national.  With  the  exception  of 
having  adopted  almost  exclusively  the  French  and  German  dorsal 
decubitus  in  making  use  of  the  instruments,  we  have  become  in  a 
measure  eclectic  in  the  selection  of  the  latter ;  medical  schools,  accou- 
cheurs, and  local  obstetrical  societies,  influencing  students  and  the 


THE    FORCEPS.  473 

junior  members  of  the  profession,  to  adopt  the  French,  German, 
English,  or  American  styles,  as  the  case  may  be,  the  forceps  them- 
selves bearing  the  names  of  .their  several  inventors,  or  compilers ; 
for  some  are  a  true  compilation,  the  blade,  from  one  contriver  ;  fenes- 
tral  openings,  another;  pelvic  curve,  a  third;  width,  a  fourth ;  shanks, 
a  fifth;  method  of  locking,  a  sixth;  etc.  etc.  For  this  reason  the 
late  Prof.  Hodge  named  his  forceps  the  eclectic,  although  in  some  re- 
spects entirely  original,  particularly  in  the  long  superimposed  shanks, 
a  great  improvement  for  operating  at  the  superior  strait,  and  avoid- 
ing the  painful  stretching  of  the  posterior  commissure.  Dr.  Hodge 
expended  a  great  deal  of  thought  and  money  in  perfecting  his  forceps, 
and  the  various  steps  in  the  process  were  marked  by  a  new  form, 
until,  from  a  heavy,  clumsy  instrument,  he  gradually  evolved  what 
was  at  one  time  regarded  as  a  wonderful  improvement  upon  the 
forceps  of  France  and  England. 

A  contemporary  of  Prof.  Hodge,  the  late  Prof.  David  D.  Davis,  ot 
London,  was  equally  anxious  to  perfect  the  instrument,  and  turned 
his  attention  especially  to  making  the  blades  light,  open,  and  to  so 
fit  the  sides  of  the  foetal  head  as  to  enable  traction  to  be  made  with- 
out much  pressure,  or  leaving  any  mark  on  the  child's  scalp.  There 
is  a  principal  of  mechanics  involved  in  his  instrument,  which  he 
studied  to  perfect,  by  moulding  the  blades  so  as  to  obtain  conside- 
rable coaptating  surface,  and  thus  by  increase  of  friction  avoid  undue 
and  dangerous  pressure.  The  Davis  blade  soon  began  to  effect 
changes  in  the  form  of  American  forceps,  and  by  the  addition  of 
long  handles,  and  some  alterations  of  shape,  weight,  and  curve,  be- 
came a  leading  feature  in  those  bearing  the  names  of  William  Harris, 
Prof.  "Wallace,  of  the  Jefferson  Medical  College,  Dr.  Bethel,  and 
Albert  H.  Smith,  all  of  this  city.  The  short  Davis  instrument  was 
a  great  favorite  of  the  late  Prof.  Meigs,  and  Dr.  William  Harris,  both 
largely  engaged  in  obstetrical  practice,  as  well  as  teaching,  and  many 
a  delicate  woman,  with  wasting  forces,  was  aided  in  her  delivery  at 
their  hands,  and  surprised  to  find  no  mark  on  the  baby's  head,  and 
that  her  own  sufferings  could  be  so  gently  and  safely  relieved. 

Although  such  was  the  estimation  of  the  Davis  blade,  and  still  is 
in  many  parts  our  country,  it  does  not  appear  to  have  retained  its 
popularity,  or  been  adopted,  as  its  mechanical  perfection  would  lead 
one  who  appreciates  it  to  suppose  it  would  have  been.  In  Great 
Britain,  the  favorite  forms  now  in  use  are  but  a  very  slight  improve- 
ment upon  the  forceps  of  a  hundred  years  ago,  except  in  finish  and 
material,  the  open  fenestrae  and  bevelled  blades  of  Davis  being  de- 
clined in  favor  of  the  looped  fenestroe  and  flat-edged  blades  in  use- 
when  he  made  his  experiments  and  changes.  This  appears  to  have 
grown  out  of  a  practice  which  has  been  largely  adopted  in  Germany, 
Great  Britain,  and  many  parts  of  the  United  States,  in  applying  the 
forceps  to  the  foetal  head,  the  blades  being  introduced  at  the  sides  of 
the  pelvis,  without  much  reference  to  the  position  which  the  head 
occupies.  As  compression  is  objected  to,  the  blades  are  made  long 
and  widely  separated  (3|  to  3|),  and  the  handles  short,  so  as  not  to 
allow  of  much  leverage.  As  the  blades  do  not  fit  the  head,  the 
31 


474 


OBSTETRIC    OPERATIONS. 


mechanism  of  labor  as  taught  by  Hodge  has  been  much  simplified, 
as  it  is  not  necessary  to  learn  all  the  oblique  fittings  of  the  fenestrae 
over  the  parietal  protuberances  or  ears.  Dr.  Meigs  used  to  tell  the 
students  that  the  forceps  was  the  " child's  instrument"  and  should  be 
used  as  a  tractor ;  and  it  was,  as  a  well  applied  mechanical  tractor 
that  he  advocated  the  use  of  the  Davis  blades,  against  those  of  Sie- 
bold,  Levret,  Baudelocque,  and  Haighton,  employed  generally  in  our 
country  forty  years  ago.  His  language  is  not  very  complimentary 
to  what  he  denominates  by  distinction  "  the  mother's  instrument"  the 
form  being  better  adapted  for  saving  the  woman  than  the  foetus. 
("  Obstetrics,"  p.  540.) 

At  the  present  day  we  have  two  general  varieties  of  forceps  in 
use  in  the  United  States ;  under  each  of  which  may  be  placed  a  vast 
number  of  special  forms,  which  are  simply  changes  upon  one  or  the 
other  general  type,  according  to  the  fancy  of  the  inventor.  At  the 
head  of  one  type,  may  be  placed  the  long  forceps  of  Prof.  Hodge, 
designed  to  be  adapted  to  the  sides  of  the  child's  head 
FIG.  158.  in  all  possible  cases:  and  of  the  other,  those  of  Prof. 
Simpson,  of  Edinburgh,  or  their  modification  by  Profs. 
Elliot  and  Bedford,  of  New  York,  intended  to  be  used 
as  tractors,  and  applied  in  reference  to  the  sides  of 
the  mother's  pelvis,  rather  than  to  those  of  the  in- 
fant's head. 

Taking  the  long  forceps  of  Levret  and  Baudelocque 
as  improved  and  modified  by  Hodge;  with  the  blades 
of  Prof.  Davis  as  a  substitute,  and  handles  of  less 
c"urve  than  those  of  Hodge;  and  we  have  the  long 
forceps  of  Prof.  Ellerslie  Wallace,  of  the  Jefferson 
College,  the  favorite  instrument  with  those  who  pur- 
chase forceps  of  the  manufacturers  in  this  city.  Next 
in  popularity  are  the  instruments  of  Hodge,  Davis, 
and  Simpson,  Elliot,  Bedford,  and  a  few  others,  in  all 
about  a  dozen  forms  that  are  kept  in  stock.  The 
improvement  of  the  late  Prof.  Elliot  upon  the  instru- 
ment of  Simpson,  consists  in  narrowing  and  length- 
ening the  shanks;  widening  somewhat  the  fenestne; 
elongating  the  blades;  giving  greater  security  against 
slipping  in  the  handles;  and  gauging  the  distance 
between  the  blades  by  a  milled-head  screw-stop  in 
the  end  of  the  handles:  the  shanks  and  blades  are  an 
exact  counterpart  of  the  Miller  forceps  of  England, 
which  appeared  about  the  same  time,  1858. 

The  Hodge  forceps  were  based  in  their  contrivance 
upon  the  following  points:    1.  The  instrument  should 
be  shaped  to  the  contour  of  the  foetal  head,  and  have 
sufficient  play  to  allow  of  compression,  where  the 
Hodge  Forceps.       pelvis  is  too  narrow  for  the  head  to  pass  in  its  normal 
condition.     2.  The  blades  should  be  so  arranged  in 
reference  to  the  shanks  and  handles  as  to  enable  them  to  seize  the 
head  of  the  foetus  in  its  bi-parietal  diameter  at  the  superior  straight, 


THE    FORCEPS. 


475 


and  be  drawn  upon  in  the  direction  of  the  curve  of  the  pelvic  canal 
until  the  delivery  is  complete.  3.  The  long  forceps  ought  to  be 
competent  to  act  either  at  the  superior  strait  of  the  pelvis,  in  its 
cavity,  or  at  its  outlet,  so  as  to  avoid  a  multiplicity  of  instruments 
and  their  attendant  expense.  And  4-.  The  instrument  should  not 
cut  the  scalp  of  the  child  if  properly  adjusted,  or  injure  the  soft 
parts  of  the  mother. 

It  would  be  folly  to  claim  that  all  this  could  or  has  been  accom- 
plished ;  as  there  must  necessarily  be  exceptional  cases  in  all  the  points 
given;  hence  the  contrivance  of  the  forceps  of  Tarnier  and  Cleemann 
for  certain  presentations  above  the  superior  strait ;  and  the  long  and 
short  convertible  instruments  of  a  few  inventors.  There  are  many 
cases  of  labor  in  the  higher  walks  of  life  where,  although  there  is 
no  obstruction,  still  the  women  require  manual  or  instrumental 
assistance,  as  they  cannot  deliver  themselves  for  want  of  sufficient 
contractile  muscular  force.  Such  women  require  that  the  forceps 
used  should  be  easily  introduced;  should  act  simply  as  tractors; 
control  the  movement  of  the  foetal  head  by  being  well  fitted  to  its 
shape,  and  leave  no  effect  upon  the  scalp  or  vulva.  Although  these 
requisites  may  be  filled  by  the  Hodge  instrument,  it  is  this  class  of 
cases  that  has  demanded  a  lighter  and  more  roomy  pair  of  forceps, 
such  as  that  devised  by  Davis. 

As  the  teaching  of  the  Jefferson  FIG-  159.  FIG.  160. 

Medical  College  under  Dr.  Meigs, 
favored  as  we  have  stated  the  for- 
ceps of  Davis,  so  his  successor  in 
carrying  out  in  a  measure  the 
same  views,  has  combined  the 
blades  of  the  Davis  pattern,  with 
the  long  handles  of  Hodge,  in  con- 
triving the  Wallace  forceps,  now 
so  much  in  use  by  the  large  number 
of  graduates  of  this  school.  As 
compared  with  the  Hodge  instru- 
ment, it  is  one  inch  shorter  (15 
inches  against  16);  the  blades  are 
of  the  same  length  (6  inches)  the 
fenestras  are  more  open ;  the  shanks 
are  only  half  the  length,  giving  a 
much  greater  compressing  power; 
and  the  handles  are  of  the  same 
measurement  from  pivot  to  hooks. 
Both  have  the  Siebold  lock,  over 
which  we  believe  the  broad-topped 
button  and  notch  to  possess  some 
advantages ;  and  the  Wallace  is 
somewhat  heavier  than  the  Hodge 
which  should  weigh  17  ounces. 

The  short  Davis  instrument 
made  for  Prof.  Meigs  under  direc- 
tion Of  the  inventor  Weighed  lOf  Wallace  Forceps.  Davis  Forceps. 


476 


OBSTETRIC    OPERATIONS. 


ounces,  and  measured  12  inches  in  length;  fenestrte  5  inches  long,  2 
inches  wide;  blades  separated  2|  inches.  Handles  4J  inches  to  lock, 
which  was  of  the  Smellie  or  English  pattern.  A  recently  purchased 
pair  in  possession  of  the  editor  is  13|  inches  long,  with  5  inch  handles, 
a  button  lock,  2  inch  close  set  shanks,  and  6|  inch 
FIG.  ici.  blades.  We  believe  the  changes  are  decided  im- 
provements, especially  the  lock  and  elongated 
handles.  It  has  answered  admirably  in  adynamic 
cases,  requiring  only  a  few  pounds  of  tractile  assist- 
ance. The  Davis  blades  have  been  added  to  long 
handles,  and  the  whole  made  of  steel  and  marvel- 
lously light,  at  the  special  request  of  a  few  accouch- 
eurs, who  wished  them  to  aid  in  some  cases  of  arrest 
at  the  perineum. 

The  late  Prof.  George  T.  Elliot,  of  New  York, 
who  received  much  of  his  practical  obstetrical  train- 
ing in  the  Dublin  Lying-in  Hospital,  imbibed  the 
teachings  of  the  English  school,  and  became  im- 
pressed with  the  value  of  the  system  as  taught  by 
Simpson;    after    the    principle    of    whose   forceps, 
modelled  somewhat  after  that  of  the  late  Prof.  Gun- 
ning G.  Bedford,  of  New  York,  he  in  1858,  presented 
to  the  medical  profession  the  instrument  that  bears 
his  name.     The  forceps  of  Prof.  Bedford  has  a  trac- 
tion ring  on  each  side,  where  the  Elliot  has  a  cornu, 
has   a  button  joint,  instead  of  a  Smellie,  has    no 
screw  stop,  and  has  diverging,  instead  of  superim- 
posed shanks.     These  points  have   generally  been 
considered  as  improvements,  and  hence  the  Elliot 
has   taken   precedence   in  large  measure  over  the 
Bedford  instrument   in   New  York   sales,  the  two 
being  the  leading  forceps  in  demand.     The  instru- 
Eiiiot  Forceps.        ment  of  White,  of  Buffalo,  is  perhaps   next,  and 
then  Hodge's.     But  few  of  Prof.  Wallace's  forceps, 
the  leading  instrument  in  the  Philadelphia  trade,  are  ordered.     The 
White  is  a  long  forceps,  a  compound  of  the  Elliot  blade,  long  super- 
imposed shanks  of  Hodge,  Siebold  lock,  and  short  corrugated  steel 
handles  bowed  out  like  dental  forceps,  and  ending  in  thin  blunt  hooks. 
The  Sawyer  and  Simpson  short  forceps  are  about  equally  in  de- 
mand in  New  York.     The  former  is  unknown  to  the  trade  here  ;  and 
but  comparatively  few  of  the  Simpson  are  sold,  although  the  system 
of  their  application  has  several  advocates  in  Philadelphia. 

We  have  here  a  representation  of  one  of  the  lightest  of  all  the 
varieties  of  the  short  forceps,  weighing  but  5  ounces,  and  measuring 
9 f  inches  in  length  ;  the  handle  being  3  inches,  shank  1J,  and  chord 
of  blade-curve  5J.  The  blades  are  1£  inches  wide,  with  oval  fenes- 
trae  $  inch  wide,  and  are  separated  2f  inches  at  their  widest  part, 
and  f  inch  at  the  tips. 

This  instrument  was  invented  about  two  years  and  a  half  ago,  by 
Prof.  Edw.  Warren  Sawyer,  of  Eush  Medical  College,  Chicago,  ami 


THE    FORCEPS. 


477 


has  been  highly  commended  by  Prof.  By  ford  and  others.  The  for- 
ceps have  the  blades  of  Davis,  superimposed  shanks  of  Hodge,  and 
lock  of  Smellie,  with  hard-rubber  plates 
moulded  hot  upon  the  handles.  The  several 
parts  have  been  somewhat  modified ;  the  ob- 
ject being  to  secure  a  tractor  for  cases  of  defi- 
cient expulsive  force,  where  the  foetal  head  is 
low  in  the  pelvis. 

Professor  Sawyer  says :  "  In  the  labors  to 
which  my  forceps  are  applicable  it  is  not  ne- 
cessary for  the  operator's  body  to  be  in  line 
with  the  pelvic  axis.  My  mode  of  procedure 
is  the  following:  The  woman  is  placed  upon 
her  back  and  drawn  to  the  edge  of  the  bed, 
the  outside  leg  is  now  flexed ;  beneath  this 
flexed  extremity  and  the  bed  covering,  I  apply 
the  forceps — often  using  but  one  hand  in  the 
operation.  When  the  instrument  is  locked,  I 
grasp  the  handle  in  such  a  manner  that  the 
palm  of  the  hand  looks  upward :  one  hook 
then  rests  naturally  upon  the  extensor  surface 
of  the  first  phalanx  of  the  index  finger,  while 
the  other  hook  rests  upon  a  corresponding 
part  of  the  thumb.  When  thus  adjusted,  I 
lift  the  head  from  the  pelvic  outlet,  at  the  same 
time  invoking  the  pendulum  movement  if  de- 
sired. At  this  moment  the  advantage  of  the 
hooked  handle  is  very  apparent  to  the  opera- 
tor." ..."  All  practitioners  must  have  often  felt,  during  the 
last  moments  of  labor,  when  the  uterus  and  the  mother  seemed 
fatigued,  the  need  of  a  little  help  to  the  expulsive  powers.  The  or- 
dinary instruments  are  too  formidable  to  be  used  at  the  last  moment, 
and  it  is  then  that  this  little  forceps  is  useful." 

We  have  given  the  names  and  characters  of  the  various  forceps 
most  in  use  in  New  York  and  Philadelphia ;  and  by  the  large  num- 
ber of  graduates  of  their  respective  schools,  as  shown  by  their  pre- 
ferences in  making  purchases  of  the  leading  instrument  makers  of 
the  two  cities.  The  mechanism  of  instrumental  delivery  is  much 
simplified  by  applying  the  forceps  to  whatever  parts  of  the  foetal 
head  may  be  opposite  the  sides  of  the  pelvis  ;  but  it  is  verv  ques- 
tionable whether  it  is  the  scientific  method,  or  the  safer  for  the  child. 
With  one  blade  over  the  side  of  the  occiput,  and  the  other  over  that 
of  the  forehead,  which  is  the  manner  of  seizure  in  oblique  positions 
of  the  vertex,  we  certainly  have  not  a  very  secure  hold,  and  run 
some  risk  of  injury  to  the  foetus.  The  advocates  of  this  system 
claim  that  they  use  no  compression,  only  a  simple  traction  ;  which 
may  be  true  in  one  sense,  but  amounts  to  the  same  in  effect,  else  how 
could  Dr.  Elliot,  by  traction  with  great  force,  straighten  out  one  of 
the  blades  of  his  Simpson  forceps,  as  related  in  the  "  N.  Y.  Journ.  of 
Med."  for  September,  1858,  page  161,  in  the  paper  which  he  pre- 


Sawyer  Forceps. 


478 


OBSTETRIC    OPERATIONS. 


sented,  describing  his  new  forceps  and  a  number  of  cases  in  which, 
he  had  tested  them.  It  makes  but  little  difference  whether  we  com- 
press the  head  before  we  begin  to  pull,  or  pull  so  as  to  wedge  the 
head  between  the  blades  and  thus  compress  it,  except  as  to  the  differ- 
ence of  fit  in  the  two  instances;  the  adjusted  and  even  pressure, 
being  the  less  likely  to  injure  the  foetus.  We  have  always  believed 
that  the  forceps  should  fit  the  head,  and  that  the  student  should  be 
taught  how  to  accomplish  it  correctly  in  the  various  positions  of  the 
foetus.  If  the  student  has  a  mechanical  turn  of  mind,  a  delicate 
sense  of  touch,  and  a  clear  head,  he  will  soon  learn :  if  he  is  not  a 
mechanic,  he  will  be  forced  to  adopt  a  more  simple  method  of  de- 
livery. In  a  large  city,  there  are  but  few  first  class  obstetrical 
manipulators  as  a  general  rule,  and  they  are  usually  well  known  as 

FIG.  163. 


Application  of  the  Forceps  at  the  Inferior  Strait. 


such,  for  the  reason  that  but  few  have  all  the  requisites  to  enable 
them  to  achieve  notoriety ;  and  yet  there  are  hundreds  who  can  de- 
liver a  woman  with  forceps  moderately  well.  To  one,  the  mechan- 
ism of  Hodge  is  a  simple  matter,  and  soon  mastered;  to  another,  it  is 


THE    FORCEPS.  479 

a  useless  complication,  and  he  prefers  the  more  simple  system. 
Hence  the  great  differences  between  obstetricians,  as  to  the  best  in- 
strument, and  the  best  method  of  application.  Some  of  the  vast 
array  of  patterns  have  decided  merit,  and  display  much  mechanical 
skill ;  while  others  serve  only  to  amuse  the  educated  examiner.  One 
obstetrician,  like  Elliot,  uses  a  variety  of  forceps  one  after  another  in 
the  same  case,  and  pulls  with  great  force  ;  while  another  confines  his 
work  almost  to  one  instrument,  adjusts  it  easily,  pulls  moderately, 
and  seldom  fails.  There  are  no  doubt  exceptions,  but  certainly  the 
most  delicate  manipulators  we  have  seen,  believed  in  and  practised 
the  teachings  of  Hodge  and  Meigs.  There  may  be  cases  where  it 
might  be  well  to  practise  the  method  of  Simpson,  as  is  done  occa- 
sionally by  some  of  our  leading  practitioners ;  but  we  cannot  see 
why  his  plan  of  delivery  should  be  exclusively  used  on  any  mode  of 
scientific  reasoning. 

We  present  a  series  of  plates  in  illustration  of  the  American 
method  of  delivery  with  the  forceps ;  the  position,  as  will  be  seen, 
being  that  of  France  and  Germany- — on  the  back.  When  it  is  de- 
cided to  use  the  forceps,  in  almost  all  cases  in  the  United  States,  the 
patient  is  brought  to  the  edge  of  the  bed  on  her  back,  with  her  nates 
close  to  the  edge,  her  feet  on  two  chairs,  and  her  knees  widely  sepa- 
rated, as  in  the  plate  above.  The  patient  is  covered  with  a  sheet,  or 
heavier  covering  if  in  winter,  and  there  is  no  necessity  of  exposure, 
as  the  whole  manipulation  may  be  done  by  the  sense  of  touch.  The 
position  is  by  far  the  most  convenient  for  the  obstetrician,  and  enables 
him  much  more  easily  to  keep  in  his  mind  all  the  anatomical  rela- 
tions of  the  foetus  and  pelvis,  than  when  in  the  English  decubitus. 
We  study  the  anatomy,  with  the  subject  on  the  back,  and  the 
mechanism  of  labor  in  front  of  the  pelvis,  or  mannikin,  then  why 
complicate  matters  by  a  change  of  position,  which,  to  say  the  least, 
is  a  very  awkward  one,  particularly  in  introducing  the  long  forceps, 
setting  them  according  to  the  instructions  of  Hodge,  and  carrying 
them  forward  between  the  thighs  as  the  head  emerges  ?  We  have 
used  the  short  forceps  in  an  exhausted  case,  with  the  woman  on  her 
side,  but  found  it  much  less  convenient  for  the  various  movements,  al- 
though we  soon  delivered  the  fcetus.  As  to  the  question  of  exposure, 
there  is  less  in  appearance  than  in  fact,  in  the  English  position,  in 
many  cases.  If  the  patient  and  nurse  are  fastidious  and  careful 
during  the  use  of  the  forceps,  the  accoucheur  can  manage  without 
his  eyes  in  a  large  proportion  of  cases;  but  the  fault  of  exposure 
lies  more  frequently  in  the  temporary  reckless  indifference  begotten 
of  pain  and  suffering  in  the  woman,  than  in  any  act  of  the  accou- 
cheur, if  inclined  to  spare  the  feelings  of  his  patient  as  much  as 
possible. 

The  long  forceps,  with  its  pelvic  curve,  was  specially  designed  for 
use  at  the  superior  strait  of  the  pelvis,  the  curve  of  the  blades,  as  in 
the  Davis  instrument  modified  by  Wallace,  being  intended  to  cor- 
respond with  the  direction  of  the  occipito -mental  diameter  of  the 
foetal  head.  The  long  superimposed  shanks  of  several  varieties  of 
the  long  forceps  will  here  be  found  valuable,  as  the  lock  is  not  iritro- 


480 


OBSTETRIC    OPERATIONS 


duced,  or  the  posterior  commissure  of  the  vulva  widely  stretched. 
If  the  head  is  entirely  above  the  strait,  the  line  of  the  blades  must 
be  changed  correspondingly,  in  order  to  apply  them  properly,  and 
keep  the  line  of  traction  within  the  coccyx;  and  even  then,  to  draw 


FIG.  1G4. 


Application  of  the  Forceps  with  the  Head  at  the  Superior  Strait;  the  left  blade  held  in  place  by  an 

Assistant. 

in  the  proper  direction,  the  left  hand  must  act  at  first  in  a  backward 
direction  from  the  lock ;  while  the  right  brings  the  handles  down- 
ward, forward,  and  then  upward;  both  hands  describing  a  curve,  but 
that  of  the  right  being  much  the  greater.  The  peculiar  forceps  of 
Tarnier,  or  of  Cleernann,  being  designed  to  meet  this  form  of  exi- 
gency, may  be  brought  into  requisition. 

In  latter  years  it  has  become  much  more  common  than  formerly 
to  introduce  the  forceps  into  the  uterus,  before  it  is  fully  dilated,  in 


THE    FORCEPS. 


481 


consequence  of  the  success  claimed  for  the  plan  as  carried  out  in  the 
Dublin  Lying-in  Hospital.  As  this  should  never  be  done  where  the 
os  is  not  readily  dilatable,  and  requires  much  skill  in  execution,  it  is 
not  safe  to  recommend  its  general  adoption  in  cases  of  delay  in  pri- 
vate practice. 

The  forceps  should  not  be  introduced  with  any  force,  but  the  left 
blade  should  be  slid  in  gently,  and  with  a  spiral  motion,  and  then 
the  right;  care  being  taken  that  they  should  also  lock  without  force, 
which  they  will  do  if  properly  adjusted.  Traction  is  to  be  exerted 
slowly,  and  during  a  pain,  the  whole  movement  being  made  to  cor- 
respond with  the  natural  as  closely  as  possible. 

FIG.  165. 


Direction  of  the  Forceps  as  the  Head  is  being  Delivered. 

As  the  foetal  head  comes  under  the  arch  of  the  pubes,  the  handles 
of  the  forceps  must  rise  more  and  more  from  the  bed,  until  at  last 
they  are  over  the  abdomen,  as  the  head  emerges  from  the  perineum. 
This  last  movement  of  instrumental  delivery  should  be  a  very  slow 
one,  for  fear  of  rupture.  It  has  been  proposed  to  remove  the  blades 
before  delivery  is  complete;  but  there  is  no  occasion  for  this,  if  the 
forceps  are  applied  to  the  sides  of  the  head  over  the  parietal  protru- 
berances ;  as  where  these  protrude,  and  the  blades  are  flat  and  thin, 
there  is  very  little  additional  space  required.  With  such  instruments 
as  the  old  Levret,  Baudelocque,  and  Eohrer  forceps,  with  looped  or 


482  OBSTETRIC  OPERATIONS. 

kite-shaped  fenestroe,  and  thick  edges,  this  was  a  much  more  impera- 
tive direction,  than  with  the  better  instruments  of  the  present  day. 
With  a  Sawyer  forceps  the  perineum  ought  to  be  safer,  and  under 
better  control  than  without.  When  the  perineum  is  thought  to  be 
in  danger,  the  process  of  distension  should  be  retarded  through  two 
or  three  pains,  or  even  more  if  required,  instead  of  drawing  the  head 
through  at  once. 

After  the  head  is  delivered,  if  the  cord  is  not  around  the  neck, 
and,  therefore,  in  danger  from  pressure,  the  body  should  be  allowed 
to  remain  until  the  uterus  has  well  contracted  upon  it,  for  fear  of 
hemorrhage  after  delivery  from  uterine  inertia. — ED.] 


CHAPTER  IV. 

THE  VECTIS — THE  FILLET. 

IN  connection  with  the  subject  of  instrumental  delivery  it  is  essen- 
tial to  say  something  of  the  use  of  the  vectis,  on  account  of  the  value 
which  was  formerly  ascribed  to  it,  which  was  at  one  time  so  great  in 
this  country  that  it  became  the  favorite  instrument  in  the  metropolis; 
Denman  saying  of  it  that  even  those  who  employed  the  forceps  were 
"  very  willing  to  admit  the  equal,  if  not  superior,  utility  and  conve- 
nience of  the  vectis."  Even  at  the  present  day,  there  are  practi- 
tioners of  no  small  experience  who  believe  it  to  be  of  occasional 
great  utility,  and  use  it  in  preference  to  the  forceps  in  cases  in  which 
slight  assistance  only  is  required.  In  spite,  however,  of  occasional 
attempts  to  recommend  its  use,  the  instrument  has  fallen  into  dis- 
favor, and  may  be  said  to  be  practically  obsolete. 

Nature  of  the  Instrument. — The  vectis,  in  its  most  approved  form, 
consists  of  a  single  blade,  not  unlike  that  of  a  short  straight  forceps, 
attached  to  a  wooden  handle.  A  variety  of  modifications  exist  in  its 
shape  and  size.  The  handle  has  been  occasionally  manufactured,  for 
the  convenience  of  carriage,  with  a  hinge  close  to  the  commencement 
of  the  blade  (Fig.  166),  or  with  a  screw  at  the  point  where  the  handle 
and  blade  join.  The  power  of  the  instrument,  and  the  facility  of 
introduction,  depend  very  much  on  the  amount  of  curvature  of  the 
blade.  If  this  be  decided,  a  firmer  hold  of  the  head  is  taken  and 
greater  tractive  force  is  obtained,  but  the  difficulty  of  introduction  is 
increased. 

The  vectis  is  used  either  as  a  lever  or  a  tractor.  When  employed  in 
the  former  way,  the  fulcrum  is  intended  to  be  the  hand  of  the  ope- 
rator; but  the  risk  of  using  the  maternal  structures  as  a  point  (Tappui, 
and  the  inevitable  danger  of  contusion  and  laceration  which  must 
follow,  constitute  one  of  the  chief  objections  to  the  operation.  Its 


THE    VECTIS THE    FILLET. 


483 


value  as  a  tractor  must  always  bo  limited,  and  quite  inferior  to  that 
of  the  forceps,  while  it  is  as  difficult  to  introduce  and  manipulate. 

Cases  in  which  it  is  Applicable. — The  vectis  has  been  recommended 
in  cases  in  which  the  low  forceps  operation  is  suitable,  provided  the 
pains  have  not  entirely  ceased.  There  is  no  doubt  that  it  may  be 
quite  capable  of  overcoming  a  slight  impediment  to  the  passage  of 
the  head.  It  is  applied  over  various  parts  of  the  head, 
most  commonly  over  the  occiput,  in  the  same  manner,  FIG.  ICG. 
and  with  the  same  precautions,  as  one  blade  of  the 
forceps.  Dr.  Eamsbotharn  says  "we  shall  find  it 
necessary  to  apply  it  to  different  parts  of  the  cranium, 
and  perhaps  the  face  also,  successively,  in  order  to  re- 
lieve the  head  from  its  fixed  condition,  and  favor  its 
descent."  Such  an  operation  obviously  requires  quite 
as  much  dexterity  as  the  application  of  the  forceps; 
while,  if  we  bear  in  mind  its  comparatively  slight 
power,  and  the  risk  of  injury  to  the  maternal  struc- 
tures, we  must  admit  that  the  disuse  of  the  instrument 
in  modern  practice  is  amply  justified. 

The  vectis  may,  however,  find  a  useful  application 
when  employed  to  rectify  malpositions,  especially  in 
certain  occipito-posterior  presentations.     This  action 
of  the  instrument  has  already  been  considered  (p.  308), 
and,   under  such  circumstances,  it  may  prove  of  ser- 
vice  where  the  forceps  is  inapplicable.     When  so  em-      Hinged  Handle, 
ployed  it  is  passed  carefully  over  the  occiput,  and, 
while  the  maternal  structures  are  guarded  from  injury,  downward 
traction  is  made  during  the  continuance  of  a  pain.     So  used,  its 
application  is  perfectly  simple  and  free  from  danger,  and  for  this 
purpose  it  may  be  retained  as  a  part  of  the  obstetric  armamentarium. 

The  fillet  is  the  oldest  of  obstetric  instruments,  having  been  fre- 
quently employed  before  the  invention  of  the  forceps,  and  even  in 
the  time  of  Smellie  it  was  much  used  in  the  metropolis.  It  has 
since  completely  fallen  out  of  favor  as  a  scientific  instrument,  although 
its  use  is  every  now  and  again  advocated,  and  it  is  certainly  a  favorite 
instrument  with  some  practitioners.  This  is  to  be  explained  by  the 
apparent  simplicity  of  the  operation,  and  the  fact  that  it  can  gene- 
rally be  performed,  without  the  knowledge  of  the  patient;  the  latter, 
however,  is  one  strong  reason  why  it  should  not  be  used. 

Nature  of  the  Instrument. — The  fillet  consists,  in  its  most  improved 
form  (that  which  is  recommended  by  Dr.  Eardley  Wilmot1  (Fig.  167), 
of  a  slip  of  whalebone  fixed  into  a  handle,  composed  of  two  separate 
halves,  which  join  into  one.  The  whalebone  loop  is  slipped  over 
either  the  occiput  or  face,  and  traction  used  at  the  handle. 

Objections  to  its  Use. — When  applied  over  the  face,  after  the  head 
has  rotated,  it  would  probably  do  no  harm ;  but  if  it  were  so  placed 
when  the  head  was  high  in  the  pelvis,  traction  would  necessarily 
produce  extension  of  the  chin  before  the  proper  time,  and  would 

1  Obst.  Trans.,  vol.  xv. 


OBSTETRIC    OPERATIONS. 


FIG.  1G7  thus  interfere  with  the  natural  mechanism 

of  delivery.  If  placed  over  the  occiput,  it 
is  impossible  to  make  traction  in  the  direc- 
tion of  the  pelvic  axes,  as  the  instrument 
will  then  infallibly  slip.  If  traction  be 
made  in  any  other  direction,  there  must 
be  a  risk  of  injuring  the  maternal  struc- 
tures, or  of  changing  the  position  of  the 
head.  Hence  there  is  every  reason  for  dis- 
carding the  fillet  as  a  tractor,  or  as  a  sub- 
stitute for  the  forceps,  even  in  the  simplest 
cases. 

It  is  quite  possible  that  it  may  find  a 
useful  application  in  certain  cases  in  which 
the  vectis  ma}^  also  be  used,  viz.,  as  a  rec- 
tifier of  malposition,  and,  from  the  com- 
parative facility  of  its  introduction,  it 
would  probably  be  the  preferable  instru- 
ment of  the  two. 

[The  whalebone  fillet  was  the  great 
weapon  of  delivery  in  old  Japanese  ob- 
stetrics, and  according  to  their  obstetrical 
plates  must  have  done  fearful  execution, 
especially  when  placed  over  the  body  of  the  foetus,  and  operated 
upon  by  a  windlass.  Fortunately  for  the  native  women,  science  is 
introducing  a  more  rational  method. — ED.] 


Wilmot's  Fillet. 


CHAPTER  V. 


.      OPERATIONS  INVOLVING  DESTRUCTION  OF  THE  F(ETUS. 

OPERATIONS  involving  the  destruction  and  mutilation  of  the  child 
were  among  the  first  practised  in  midwifery.  Craniotorny  was  evi- 
dently known  in  the  time  of  Hippocrates,  as  he  mentions  a  mode  of 
extracting  the  head  by  means  of  hooks.  Celsus  describes  a  similar 
operation,  and  was  acquainted  with  the  manner  of  extracting  the 
foetus  in  transverse  presentations  by  decapitation;  similar  procedures 
were  also  practised  and  described  by  Aetius  and  others  among  the 
ancient  writers.  The  physicians  of  the  Arabian  school  not  only 
employed  perforators  for  opening  the  head,  but  were  acquainted  with 
instruments  for  compressing  and  extracting  it. 

Relicjious  Objections  to  Craniotorny. — Until  the  end  of  the  seven- 
teenth century  this  class  of  operation  was  not  considered  justifiable 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FOZTUS.          485 

in  the  case  of  living  children;  it  then  came  to  be  discussed  whether 
the  life  of  the  child  might  not  be  sacrificed  to  save  that  of  the  mother. 
It  was  authoritatively  ruled  by  the  Theological  Faculty  of  Paris,  that 
the  destruction  of  the  child  in  any  case  was  mortal  sin.  "Si  Ton  ne 
peut  tirer  1'enfant  sans  le  tuer,  on  ne  pent  sans  peche*  mortel  le  tirer." 
This  dictum  of  the  Koman  Church  had  great  influence  on  Continental 
midwifery,  more  especially  in  France,  where,  up  to  a  recent  date,  the 
leading  obstetricians  considered  craniotomy  to  be  only  justifiable  when 
the  death  of  the  foetus  had  been  positively  ascertained.  Even  at  the 
present  day  there  are  not  wanting  practitioners  who,  in  their  praise- 
worthy objection  to  the  destruction  of  a  living  child,  counsel  delay 
until  the  child  has  died;  a  practice  thoroughly  illogical,  and  only 
sparing  the  operator's  feelings  at  the  cost  of  greatly  increased  risk  to 
the  mother.  In  England,  the  safety  of  the  child  has  always  been 
considered  subservient  to  that  of  the  mother;  and  it  has  been  ad- 
mitted that,  in  every  case  in  which  the  extraction  of  a  living  foetus 
by  any  of  the  ordinary  means  is  impossible,  its  mutilation  is  perfectly 
justifiable. 

Unjustifiable  Frequency. — It  must  be  admitted  that  the  frequency 
with  which  craniotomy  has  been  performed  in  this  country  constitutes 
a  great  blot  on  British  midwifery.  Daring  the  mastership  of  Dr. 
Labbat,  at  the  Rotunda  Hospital,  the  forceps  was  never  once  applied 
in  21,867  labors.  Even  in  the  time  of  Clarke  and  Collins,  when  its 
frequency  was  much  diminished,  craniotomy  was  performed  three  or 
four  times  as  often  as  forceps  delivery.  These  figures  indicate  a 
destruction  of  foetal  life  which  we  cannot  look  back  to  without  a 
shudder,  and  which,  it  is  to  be  feared,  justify  the  reproaches  which 
our  Continental  brethren  have  cast  upon  our  practice.  Fortunately, 
professional  opinion  has  now  completely  recognized  the  sacred  duty 
of  saving  the  infant's  life,  whenever  it  is  practicable  to  do  so;  and 
British  obstetricians  now  teach,  as  carefully  as  those  of  any  other 
nation,  the  imperative  necessity  of  using  every  endeavor  to  avoid 
the  destruction  of  the  foetus. 

Division  of  the  Subject. — The  operation  now  under  consideration 
may  be  necessary:  1st,  when  the  head  requires  either  to  be  simplv 
perforated,  or  afterwards  more  completely  broken  up  and  extracted"; 
an  operation  which  has  received  various  names,  but  is  generally 
known  in  this  country  as  craniotomy,  and  which  may  or  may  not 
require  to  be  followed  by  further  diminution  of  the  trunk.  2dly, 
when  the  arm  presents,  and  turning  is  impossible ;  this  necessitates 
one  of  two  procedures,  decapitation  with  the  separate  extraction  of 
the  body  and  head,  or  evisceration.  In  both  classes  of  cases  similar 
instruments  are  employed,  and  those  generally  in  use  at  the  present 
time  may  be  first  briefly  described. 

Description  of  Instruments  Employed. — 1.  The  object  of  the  perfo- 
rator is  to  pierce  the  skull  of  the  child,  so  as  to  admit  of  the  brain 
being  broken  up,  and  the  consequent  collapse  and  diminution  in  size 
of  the  cranium.  The  perforator  invented  by  Denman,  or  some  modi- 
fication of  it,  has  been  principally  employed.  It  requires  the  handles 
to  be  separated  in  order  to  open  the  blades,  and  this  cannot  be  done 


486 


OBSTETRIC    OPERATIONS. 


by  the  operator  himself.  This  difficulty  is  overcome  in  tlie  modifi- 
cation of  Naegele's  perforator  used  in  Edinburgh,  in  which  the 
handles  are  so  constructed  that  they  open  the  points  when  pressed 
together,  and  are  separated  by  a  steel  rod,  with  a  joint  at  its  centre, 
to  prevent  their  opening  too  soon.  By  this  arrangement  the  instru- 
ment can  be  manipulated  by  one  hand  only.  The  sharp-pointed 
portion  has  an  external  cutting  edge,  with  projecting  shoulders  at 
its  base,  to  prevent  its  penetrating  too  far  into  the  cranium.  Many 
modifications  of  these  arrangements  have  since  been  contrived  (Figs. 
168,  169,  170).1  In  some  parts  of  the  Continent  and  America  a 


FIG.  168. 


FIG.  169. 


FIG.  170. 


Various  forms  of  Perforators. 

perforator  is  used  constructed  on  the  principle  of  the  trephine;  but 
this  is  vastly  more  difficult  to  work,  and  has  the  great  disadvantage 
of  simply  boring  a  hole  in  the  skull,  instead  of  splitting  it  up,  as  is 
done  by  the  sharp-pointed  instrument. 

The  instruments  for  extraction  are  the  crotchet  and  craniotomy 
forceps. 

Crotchets  and  Craniotomy  Forceps. — The  crotchet  is  a  sharp-pointed 
hook  of  highly-tempered  steel,  which  can  be  fixed  on  some  portion 
of  the  skull,  either  internal  or  external,  traction  being  made  by  the 
handle.  The  shank  of  the  instrument  is  either  straight  or  curved 
(Figs.  171  and  172),  the  latter  being  preferable,  and  it  is  either  at- 
tached to  a  wooden  handle  or  forged  in  a  single  piece  of  metal.  [The 

['  The  perforator  of  Meigs  is  simply  the  ordinary  tapping  trocar  with  a  long  handle. 
The  trepan-perforator  appears  to  have  been  first  used  by  Assalini,  of  Italy,  who  was 
soon  followed  by  Jb'rg,  of  Nurnberg.  Braun,  of  Vienna,  invented  an  instrument 
with  a  curved  tube  and  crank  handle,  which  has  been  introduced  here  as  a  curiosity. 
E.  Martin,  of  Berlin,  has  contrived  a  straight  stemmed  trephine  of  small  size.  Weiss 
and  Son,  of  London,  have  improved  the  Braun  perforator,  and  we  have  seen  it  here 
but  it  is  a  mistake  to  suppose  that  these  instruments  have  been  adopted  in  our  country. 
What  is  most  sold  is  the  perforating  scissors  (Fig.  170). — ED.] 


OPERATIONS    INVOLVING    DESTRUCTION    OF    F(ETUS. 


487 


crotchet  should  be  guarded,  to  save  the  mother  from  risk  of  lacera- 
tion in  case  it  should  slip. — ED.]  A  modification  of  this  instrument 
is  known  as  OMham's  vertebral  koolc.  It  consists  of  a  slender  hook, 
measuring,  with  its  handle,  13  inches  in  length,  which  is  passed 
through  the  foramen  magnum,  and  fixed  in  the  vertebral  canal,  so 
as  to  secure  a  firm  hold  for  traction.  All  forms  of  crotchets  are  open 
to  the  serious  objection  of  being  liable  to  slip,  or  break  through  the 
bone  to  which  they  are  fixed,  so  wounding  either  the  soft  parts  of 
the  mother,  or  the  fingers  of  the  operator  placed  as  a  guard.  Hence 
they  are  discountenanced  by  most  recent  writers, 
and  may  with  propriety  be  regarded  as  obsolete  FIGS,  m,  172. 
instruments. 

Craniotomy  Forceps  are  preferable  for  Extraction. 
— Their  place  as  tractors  is  well  supplied  by  the 
more  modern  craniotomy  forceps  (Fig.  173).  These 
are  intended  to  lay  hold  of  the  skull,  one  blade  being 
introduced  within  the  cranium,  the  other  externally, 
and,  when  a  firm  grasp  has  been  obtained,  down- 
ward traction  is  made.  A  second  object  it  fulfils 
is,  to  break  away  and  remove  portions  of  the  skull, 
when  perforation  and  traction  alone  are  insufficient 
to  effect  delivery.  Many  forms  of  craniotomy  for- 
ceps are  in  use ;  some  armed  with  formidable  teeth, 
others,  of  simpler  construction,  depending  on  their 
roughened  and  serrated  internal  surfaces  for  firm- 
ness of  grasp.  For  general  use,  there  is  no  better 
instrument  than  the  cran-ioclast  of  Sir  James  Simp- 
son (Fig.  17-i),  which  admirably  fulfils  both  these 
indications.  It  consists  of  two  separate  blades, 
fastened  by  a  button  joint.  The  extremities  of  the 
blades  are  of  a  duck-billed  shape,  and  are  sufficiently 
curved  to  allow  of  a  firm  grasp  of  the  skull  being 
taken  ; .  the  upper  blade  is  deeply  grooved  to  allow 
the  lower  to  sink  into  it,  and  this  gives  the  instru- 
ment great  power  in  fracturing  the  cranial  bones, 
when  that  is  found  to  be  necessary.  It  need  not,  however,  be  em- 
ployed for  the  latter  purpose,  and,  the  blades  being  serrated  on  their 
under  surface,  form  as  perfect  a  pair  of  craniotomy  forceps  as  any  in 
ordinary  use.  Provided  with  it,  we  are  spared  the  necessity  of  pro- 
curing a  number  of  instruments  for  extraction. 

Cephalotribe. — Amongst  modern  improvements  in  midwifery  there 
are  few  which  have  led  to  more  discussion  than  the  use  of  the 
cephalotribe.1  The  instrument,  originally  invented  by  Baudelocque, 
was  long  employed  on  the  Continent  before  it  was  used  in  this  country, 
the  prejudice  against  it  being  no  doubt  due  to  its  formidable  size  and 
appearance.  Of  late  years  many  of  our  leading  obstetricians  have 
used  it  in  preference  either  to  the  crotchet  or  craniotomy  forceps,  and 


Crochets. 


1  [Assalini's  "Forcipe  Compressore,"  was  in  use  twenty  years  before  Baudelocque' s 
Cephalotribe — ED.] 


488 


OBSTETRIC    OPERATIONS. 


have  materially  modified  and  improved  its  construction,  so  that  the 
most  objectionable  features  of  the  older  instruments  are  not  entirely 
removed. 

Object  of  the  Instrument, — The  cephalotribe  consists  of  two  power- 
ful solid  blades,  which  are  applied  to  the  head  after  perforation,  and 
approximated  by  means  of  a  screw  so  as  to  crush  the  cranial  bones, 
and  after  this  it  may  be  also  used  for  extraction.  The  peculiar  value 
of  the  instrument  is,  that,  when  properly  applied,  it  crushes  the  firm 
basis  of  the  skull,  which  is  left  untouched  by  craniotomy,  or,  if  it 
does  not,  it  at  least  causes  the  base  to  turn  edgeways  within  the 


FIG.  173. 


FIG.  174. 


Craniotomy  Forceps, 


Simpson's  Cranioclast. 


blades,  so  as  to  be  in  a  more  favorable  position  for  extraction.  An- 
other and  specially  valuable  property  is,  that  it  crushes  the  bones 
within  the  scalp,  which  forms  a  most  efficient  protective  covering  to 
their  sharp  edges ;  in  this  way  one  of  the  principal  dangers  of  crani- 
otomy— the  wounding  of  the  maternal  passages  by  spiculae  of  bone — 
is  entirely  avoided. 

The  cephalotribe,  therefore,  acts  in  two  ways ;  as  a  crusher,  and 
as  a  tractor.  Some  obstetricians  believe  the  former  to  be  its  more 
important  use,  and  even  maintain  that  the  cephalotribe  is  unsuited 
for  traction.  This  view  is  specially  maintained  by  Pajot,  who  teaches 
that,  after  the  size  of  the  skull  has  been  diminished  by  repeated 
crushings,  its  expulsion  should  be  left  to  the  natural  powers.  There 
are  some  grounds  for  believing  that  in  the  greater  degrees  of  obstruc- 
tion the  tractile  power  of  the  instrument  should  not  be  called  into 
use;  but,  in  the  large  majority  of  cases,  the  facility  with  which  the 
crushed  head  may  be  withdrawn  by  it  constitutes  one  of  its  chief 
claims  to  the  attention  of  the  obstetrician.  No  one  who  has  used  it 
in  this  way,  and  experienced  the  rapid  and  easy  manner  in  which  it 
accomplishes  delivery,  can  have  any  doubt  on  this  point. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  F(ETUS. 


489 


FIG.  175. 


Its  Value.  —  There  is  every  reason  to  believe  that  cephalotripsy 
will  be  much  extended  in  this  country,  and  that  it  will  be  considered, 
as  I  believe  it  unquestionably  deserves  to  be,  the  ordinary  operation 
in  cases  requiring  destruction  of  the  foetus.  The  comparative  merits 
of  cephalotripsy  and  craniotomy  will  be  subsequently  considered. 

Description  of  the.  Instrument.  —  The  most  perfect  cephalotribc  is 
probably  that  known  as  Braxton  Ilicks's  (Fig.  175),  which  is  a  modi- 
fication of  Simpson's.  It  is  not  of 
unwieldy  size,  but  sufficiently  power- 
ful  for  any  case,  and  not  extravagant 
in  price.  The  blades  have  a  slight 
pelvic  curve,  which  materially  facili- 
tates their  introduction,  yet  not  suffi- 
ciently marked  to  interfere  with  their 
being  slightly  rotated  after  applica- 
tion. Dr.  Kidd,  of  Dublin,  prefers  a 
straight  blade  ;  while  Dr.  Matthews 
Duncan  thinks  it  better  to  use  a  some- 
what bulkier  instrument,  modelled  on 
the  type  of  the  Continental  cephalo- 
tribes.  The  principle  of  action  of  all 
these  is  identical,  and  their  differences 
are  not  of  very  material  importance. 

Section^of  the  Skull  l>y  the  Forceps- 
saw,  or  Ecraseur.  —  Another  mode  of 
diminishing  the  foetal  skull  is  by  re- 
moving it  in  sections.  This  object  is 
aimed  at  in  the  forc.eps-saw  of  Van 
Huevel,  which  consists  of  two  large 
blades,  not  unlike  those  of  the  cepha- 
lotribe  in  appearance.  Within  these 
there  is  a  complicated  mechanism, 
working  a  chain  saw  from  below  up- 
wards, which,  cuts  through  the  foetal 
skull  ;  the  separated  portions  are  sub- 
sequently withdrawn  piecemeal.  This 
instrument  is  highly  spoken  of  by  the 
Belgian  obstetricians,  who  believe  that 
it  affords  by  far  the  safest  and  most  effectual  way  of  reducing  the 
bulk  of  the  foetal  skull.  In  this  country  it  is  practically  unknown  ; 
and,  although  it  must  be  admitted  to  be  theoretically  excellent,  the 
complexity  and  cost  of  the  apparatus  have  always  stood  in  the  way 
of  its  being  used. 

Dr.  Barnes  has  suggested  that  the  same  results  may  be  obtained 
by  dividing  the  head  with  a  strong  wire  ecraseur.  So  far  as  I  know, 
this  suggestion  has  never  yet  been  carried  out  in  practice,  not  even 
by  himself,  and,  therefore,  it  is  not  possible  to  say  much  about  it.  I 
should  imagine,  however,  that  there  would  be  considerable  difficulty 
in  satisfactorily  passing  the  loop  of  wire  over  the  skull,  in  a  pelvis 
in  which  there  is  any  well-marked  deformity. 
32 


mciw's 


400  OBSTETRIC  OPERATIONS. 

Cases  requiring  Craniotomy. — The  most  common  cause  for  which 
craniotorny  or  cephalotripsy  is  performed,  is  a  want  of  proper  pro- 
portion between  the  head  and  the  maternal  passages.  This  may 
arise  from  a  variety  of  causes.  The  most  important,  and  that  most 
often  necessitating  the  operation,  is  osseous  deformity.  This  may 
exist  either  in  the  brim,  cavity,  or  outlet,  and  it  is  most  often  met 
\vith  in  the  antero-posterior  diameter  of  the  brim.  Obstetric  au- 
thorities differ  considerably  as  to  the  precise  amount  of  contraction 
which  will  prevent  the  passage  of  a  living  child  at  term.  Thus 
Clarke  and  Burns  believe  that  a  living  child  cannot  pass  through  a 
pelvis  in  which  the  antero-posterior  diameter  at  the  brim  is  less  than 
3 \  inches.  Bamsbotham  fixes  the  limit  at  3  inches,  and  Osborne  and 
Hamilton  at  2|  inches.  The  latter  is  the  extreme  limit  at  which  the 
birth  of  a  living  child  is  possible ;  but  there  can  be  no  doubt  that, 
under  favorable  circumstances,  it  may  be  possible  to  draw  the  foetus, 
after  turning,  through  a  pelvis  of  that  size.  The  opposite  limit  of 
the  operation  is  still  more  open  to  discussion.  Various  authorities 
have  considered  it  quite  possible  to  draw  a  mutilated  foetus  through 
a  pelvis  in  which  the  antero-posterior  diameter  does  not  exceed  1| 
inches,  and,  indeed,  have  succeeded  in  doing  so.  But  then  there 
must  be  a  fair  amount  of  space  in  the  transverse  diameter  of  the 
pelvis  to  admit  of  the  necessary  manipulations.  If  there  be  a  clear 
space  here  of  3  inches  and  upwards,  it  is  no  doubt  possible  to  deliver 
per  vias  naturales;  but  in  such  extreme  deformities,  the  difficulties 
are  so  great,  and  the  bruising  of  the  maternal  structures  so  extensive, 
that  it  becomes  an  operation  of  the  greatest  possible  severity,  with 
results  nearly  as  unfavorable  to  the  mother  as  the  C*sarean  section. 
Hence  some  Continental  authorities  have  not  scrupled  to  prefer  the 
latter  operation  in  the  worst  forms  of  pelvic  deformity.  The  rule  in 
English  practice  always  has  been  that  craniotomy  must  be  performed 
whenever  it  is  practicable ;  and  there  can  be  no  doubt  that  it  is  the 
right  one.  [The  operation  may  be  practicable,  and  still  be  more 
dangerous  than  the  Caesarean  section.  Where  experience  shows  this 
to  be  the  case,  we  should  in  the  United  States  elect  the  latter  and 
perform  it  early. — ED.] 

Limits  of  the  Operation. — Between  from  2f  to  3  inches  antero-pos- 
terior diameter  in  the  one  direction,  and  If  inches  in  the  other,  may 
be  said  to  be  the  limits  of  craniotomy,  provided,  in  the  latter  case, 
there  be  a  fair  amount  of  space  in  the  transverse  diameter.  The 
same  limits  may  be  laid  down  with  regard  to  tumors  or  other  sources 
of  obstruction. 

Other  Causes  justifying  Craniotomy. — There  are  a  few  other  con- 
ditions in  which  craniotomy  is  justifiable,  independently  of  pelvic 
contraction,  such  as  certain  conditions  of  the  soft  parts  which  are 
supposed  to  render  the  passage  of  the  head  peculiarly  dangerous  to 
the  mother.  Among  them  may  be  mentioned  swelling  and  inflam- 
mation of  the  vagina  from  the  length  of  the  previous  labor,  bands 
and  cicatrices  in  the  vagina,  and  occlusion  and  rigidity  of  the  os.  It 
is  hardly  too  much  to  say  that  with  a  proper  use  of  the  resources  of 
midwifery,  the  destruction  of  a  living  foetus  for  any  of  these  condi- 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS.          401 

tions  might  be  obviated.  The  most  common  of  them  is  undoubtedly 
swelling  of  the  soft  parts  causing  impaction  of  the  head ;  an  occur- 
rence which  ought  to  be  invariably  prevented  by  a  timely  use  of  the 
forceps.  Should  interference  unfortunately  be  delayed  until  impac- 
tion has  actually  taken  place,  doubtless  no  other  resource  but  crani- 
otomy  would  be  left ;  but  such  cases,  it  is  to  be  hoped,  are  now  of 
rare  occurrence  in  British  practice.  Undue  rigidity  of  the  os  can  be 
overcome  by  dilatation  with  the  caoutchouc  bags,  or,  in  more  serious 
cases,  by  incision,  which  would  certainly  be  less  perilous  to  the 
mother  than  dragging  even  a  mutilated  foetus  through  the  small  and 

oo       o  o 

rigid  aperture.  In  the  case  of  bands  and  cicatrices  in  the  vagina, 
dilatation  or  incision  will  generally  suffice  to  remove  the  obstruction; 
but  even  were  this  not  so,  here,  as  in  excessive  rigidity  of  the  peri- 
neum, it  would  be  better  that  slight  lacerations  should  take  place, 
than  that  the  child  should  be  killed. 

Complications  of  Labor  justifying  Craniotomy. — Certain  complica- 
tions of  labor  are  held  to  justify  craniotomy,  such  as  rupture  of  the 
uterus,  convulsions,  and  hemorrhage.  The  application  of  the  forceps 
or  turning  will  generally  answer  our  purpose  equally  well,  especially 
as  we  have  the  means  of  dilating  the  os  sufficiently  to  admit  of  one 
or  other  of  them  being  performed,  when  the  natural  dilatation  is  not 
sufficient.  Craniotomy  in  rupture  of  the  uterus  will  also  be  rarely 
indicated,  as  we  have  seen  that  gastrotomy  appears  to  afford  a  better 
chance  to  the  mother  in  those  cases  in  which  the  foetus  has  partially 
or  entirely  escaped  from  the  uterine  cavity. 

Excessive  Size  of  the  Foetus. — Want  of  proportion  between  the  foetus 
and  the  pelvis,  depending  on  undue  size  of  the  head,  either  natural, 
or  the  result  of  disease,  may  render  the  operation  essential.  In  the 
former  of  these  cases  we  shall  generally  have  first  attempted  delivery 
with  the  forceps,  and,  if  it  has  failed,  there  can  be  no  doubt  as  to  the 
propriety  of  lessening  the  bulk  of  the  head  by  perforation. 

Craniotomy  when  the  Child  is  believed  to  be  Dead. — In  most  obstetric 
works  we  are  recommended  to  perforate,  rather  than  apply  the  for- 
ceps, when  we  are  convinced  that  the  child  has  ceased  to  live.  This 
advice  is  based  on  the  greater  facility  with  which  craniotomy  can 
be  performed,  and  its  supposed  greater  safety  to  the  mother.  There 
can  be  no  doubt  of  the  ease  with  which  the  child  can  be  extracted 
after  perforation,  when  the  pelvis  is  not  contracted;  and,  if  we  could 
always  be  sure  of  our  diagnosis,  the  rule  might  be  a  good  one.  Be- 
fore acting  on  it,  however,  we  must  bear  in  mind  the  extreme  diffi- 
culty of  positively  ascertaining  the  death  of  the  foetus.  Of  the  signs 
usually  relied  on  for  this  purpose,  there  are  scarcely  any  which  are 
not  open  to  fallacy,  except  peeling  of  the  scalp,  and  disintegration  of 
the  cranial  bones  (which  do  not  take  place  unless  the  child  has  been 
dead  for  a  length  of  time),  and  they  are,  therefore,  useless,  in  most 
instances.  Discharge  of  the  meconium  constantly  takes  place  when 
the  child  is  alive;  a  cold  and  pulseless  prolapsed  cord  may  belong  to 
a  twin;  and  the  foetal  heart  may  become  temporarily  inaudible, 
although  the  child  is  not  dead.  If,  indeed,  we  have  carefully  watched 
the  foetal  heart  all  through  the  labor,  and  heard  it  become  more  and 


492 


OBSTETRIC    OPERATIONS. 


FlG.  176. 


more  feeble,  and  final!}'  stop  altogether,  we  might  be  certain  that  the 
child  has  died;  but  surely  such  observations  would  rather  indicate 
an  early  recourse  to  the  forceps  or  version,  so  as  to  obviate  the  fatal 
result  we  know  to  be  impending. 

In  certain  breech  presentations,  or  after  turning,  it  may  be  found 
impossible  to  extract  the  head,  without  diminishing  its  size  by  per- 
forating behind  the  ear.  In  such  cases  we  know  to  a  certainty 
whether  the  child  be  alive  or  dead,  before  resorting  to  the  operation. 
The  first  step,  whether  we  resort  to  cephalotripsy  or  craniotomy, 
is  perforation,  which  will,  therefore,  be  first  described.  In  the  former 
the  desirability  of  first  perforating  the  head  is  not  always  recognized. 
To  endeavor  to  crush  the  head  without  perforating  is  needlessly  to 
increase  the  difficulties  of  the  case,  and  it  should  be  remembered,  as 
a  cardinal  rule,  that  perforation  is  an  essential  preliminary  to  the 
proper  use  of  the  cephalotribe. 

Method  of  Perforation. — Before  perforating  we  must  carefully  ascer- 
tain the  exact  relation  of  the  os  to  the  presenting  part,  since,  in  many 

cases,  the  operation  is  performed 
before  the  os  is  fully  dilated,  when 
there  is  a  risk  of  wounding  the 
cervix.  Two  or  more  fingers  of 
the  left  hand  should  be  passed  up 
to  the  head,  and  placed  against  the 
most  prominent  part  of  the  parietal 
bone.  Under  these,  used  as  a  guard 
(Fig.  176),  the  perforator  should  be 
cautiously  introduced  until  the 
scalp  is  reached.  It  is  important 
to  fix  on  a  bony  part  of  the  skull, 
and  not  on  a  suture  or  fontanelle, 
for  puncture,  because  our  object 
is  to  break  up  the  vault  of  the 
cranium  as  much  as  possible,  so 
as  to  allow  the  skull  to  collapse. 
When  the  instrument  has  reached 
the  point  we  have  selected,  it  should 
be  made  to  penetrate  the  scalp  and 
skull  with  a  semi-rotatory  boring 
motion,  and  advanced  until  it  has 
sunk  up  to  the  rests,  which  will 
oppose  its  further  progress.  Occa- 
sionally considerable  force  will  be 
necessary  to  effect  penetration, 
more  especially  if  the  scalp  be 
swollen  by  long-continued  pres- 
sure ;  and  this  stage  of  the  opera- 
tion will  be  facilitated  by  causing  an  assistant  to  steady  the  head  by 
pressure  on  the  foetus  through  the  abdomen,  more  especially  if  it  be 
still  free  above  the  pelvic  brim.  We  must  then  press  together  the 
handles  of  the  instrument,  which  will  have  the  effect  of  widely 


Perforation  of  the  Skull. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETU3.          493 

separating  the  cutting  portion,  and  making  an  incision  through  the 
bones.  After  this  the  point  should  be  turned  round,  and  again 
opened  at  right  angles  to  the  former  incision,  so  as  to  make  a  free 
crucial  opening.  During  this  process  care  must  be  taken  to  bury 
the  perforator  in  the  skull  up  to  the  rests,  so  as  to  avoid  the  possi- 
bility of  injuring  the  maternal  soft  parts.  The  instrument  should 
now  be  introduced  within  the  skull  and  moved  freely  about,  so  as 
to  thoroughly  and  completely  break  up  the  brain.  Especial  care 
must  be  taken  to  reach  the  medulla'  oblongata  and  base  of  the  brain, 
for,  if  these  were  not  destroyed,  we  might  subject  ourselves  to  the 
distress  of  extracting  a  child  in  whom  life  was  not  extinct.  If  this 
part  of  the  operation  be  thoroughly  performed,  there  will  be  no 
necessity  for  washing  out  the  brain  by  the  injection  of  warm  water, 
as  is  sometimes  recommended,  for  the  broken-up  tissue  will  escape 
freely  through  the  opening  made  by  the  perforator. 

Perforation  of  the  After-coming  Head. — The  perforation  of  the 
after-corning  head  does  not  generally  offer  any  particular  difficulty. 
It  is  accomplished  in  the  same  manner,  the  child's  body  being  well 
drawn  out  of  the  way  by  an  assistant.  The  point  of  the  perforator, 
carefully  guarded  by  the  finger,  is  guided  up  to  the  occiput,  or  behind 
the  ear,  where  it  is  inserted. 

It  is  sometimes  useful  to  Postpone  Extraction. — If  there  be  no  neces- 
sity for  very  rapid  delivery,  and  the  pains  be  still  present,  it  is  often 
advisable  to  wait  ten  minutes  or  a  quarter  of  an  hour  before  pro- 
ceeding to  extract.  This  delay  will  allow  the  skull  to  collapse  and 
become  moulded  to  the  cavity  of  the  pelvis,  when  forced  down  by 
the  pains,  and  possibly  the  natural  efforts  may  suffice  to  finish  the 
labor  in  that  time  ;  or,  at  least,  the  head  will  have  descended  further, 
and  will  be  in  a  better  position  for  extraction.  Should  perforation 
be  required  after  having  failed  to  deliver  with  the  forceps — and  this 
is  only  likely  to  be  the  case  when  the  obstruction  is  comparatively 
slight — it  is  certainly  a  good  plan  to  perforate  without  removing  the 
forceps,  which  may  then  be  used  as  tractors. 

We  have  now  to  decide  on  the  method  of  extraction,  and  our 
choice  lies  between  the  cephalotribe  and  the  craniotomy  forceps. 

Comparative  merits  of  Cephalotripsy  and  Craniotomy. — Those  who 
have  used  both  must,  I  think,  admit  that  in  any  ordinary  case,  in 
which  the  obstruction  is  not  great,  and  only  a  comparatively  slight 
diminution  in  the  size  of  the  head  is  required,  cephalotripsy  is  infi- 
nitely the  easier  operation.  The  facility  with  which  the  skull  can 
be  crushed  is  sometimes  remarkable,  and  those  who  will  take  the 
trouble  to  read  the  reports  of  the  operation  published  by  Braxton 
Hicks,  Kidd,  and  others,  cannot  fail  to  be  struck  with  the  rapidity 
with  which  the  broken-down  head  may  often  be  extracted.  This  is 
far  from  being  the  case  with  the  craniotomy  forceps,  even  when  the 
obstruction  is  moderate  only ;  for  it  may  be  necessary  to  use  conside- 
rable traction,  or  the  blades  may  take  a  proper  grasp  with  difficulty, 
or  it  may  be  essential  to  break  down  and  remove  a  considerable 
portion  of  the  vault  of  the  cranium  before  the  head  is  lessened  suffi- 
ciently to  pass.  During  the  latter  process,  however  carefully  per- 


404  OBSTETRIC  OPERATIONS. 

formed,  there  is  a  certain  risk  of  injuring  the  maternal  structures, 
and,  in  the  hands  of  a  nervous  or  inexperienced  operator,  this  dan- 
ger, which  is  entirely  avoided  in  cephalotripsy,  is  far  from  slight. 
The  passage  of  the  blades  of  the  cephalotribe  is  by  no  means  difficult, 
and  I  think  it  must  be  admitted  that  the  possible  risks  attending  it 
are  comparatively  small.  On  account,  therefore,  of  its  simplicity  and 
safety  to  the  maternal  structures,  I  believe  cephalotripsy  to  be  de- 
cidedly the  preferable  operation  in  all  cases  of  moderate  obstruction. 

When  we  approach  the  lower  limit,  and  have  to  do  with  a  very 
marked  amount  of  pelvic  deformity,  the  two  operations  stand  on  a 
more  equal  footing.  Then  the  deformity  may  be  so  great  as  to  render 
it  difficult  to  pass  the  blades  of  even  the  smallest  cephalotribe  suffi- 
ciently deep  to  grasp  the  head  firmly,  and,  even  when  they  are  passed, 
the  space  is  often  so  limited  as  to  impede  the  easy  working  of  the 
instrument.  Besides  this,  repeated  crushings  may  be  required  to 
diminish  the  skull  sufficiently.  I  attach  but  little  importance  to  the 
argument  that  the  diminution  of  the  skull  in  one  diameter  increases 
its  bulk  in  another.  The  necessity  of  removing  and  replacing  the 
blades  on  another  part  of  the  skull,  and  of  repeating  this  perhaps 
several  times,  in  the  manner  recommended  by  Pajot,  is  a  far  more 
serious  objection.  To  do  this  in  a  contracted  pelvis  involves,  of 
necessity,  the  risk  of  much  contusion.  Fortunately  cases  of  this  kind 
are  of  extreme  rarity,  much  more  so  than  is  generally  believed,  but 
when  they  do  occur  they  tax  the  resources  of  the  practitioner  to  the 
utmost. 

On  the  whole,  the  conclusion  I  would  be  inclined  to  arrive  at  with 
regard  to  the  two  operations  is,  that  in  all  ordinary  cases,  cephalo- 
tripsy is  safer  and  easier,  whereas  in  cases  with  considerable  pelvic 
deformity,  the  advantages  of  cephalotripsy  are  not  so  well  marked, 
and  craniotorny  may  even  prove  to  be  preferable. 

Description  of  the  Operation. — The  first  step  in  using  the  cephalo- 
tribe is  the  passage  of  the  blades.  These  are  to  be  inserted  in  pre- 
cisely the  same  manner,  and  with  the  same  precautions,  as  in  the 
high  forceps  operation.  In  many  cases  the  os  is  not  fully  dilated, 
and  it  is  absolutely  essential  to  pass  the  instrument  within  it.  Special 
care  should,  therefore,  be  taken  to  avoid  any  injury  to  its  edges,  and, 
for  this  purpose,  two  or  three  fingers  of  the  left  hand,  or  even  the 
whole  hand,  should  be  passed  high  up,  so  as  thoroughly  to  protect 
the  maternal  structures.  In  order  that  the  base  of  the  skull  may  be 
reached  and  effectually  crushed,  the  blades  must  be  deeply  inserted, 
and,  in  doing  this,  great  care  and  gentleness  must  be  used.  As  the 
projecting  promontory  of  the  sacrum  generally  tilts  the  head  for- 
wards, the  handles  of  the  instrument,  after  locking,  must  be  well 
pressed  back  towards  the  perineum.  If  the  blades  do  not  lock  easily, 
or  if  any  obstruction  to  their  passage  be  experienced,  one  of  them  must 
be  withdrawn  and  re-introduced,  just  as  in  forceps  operations.  Care 
must  be  taken,  as  the  instrument  is  being  inserted,  to  fix  and  steady 
the  head  by  abdominal  pressure,  since  it  is  generally  far  above  the 
brim,  and  would  readily  recede  if  this  precaution  were  neglected. 
When  the  blades  are  in  situ,  we  proceed  to  crush  by  turning  the 
screw  slowly,  and,  as  the  blades  are  approximated,  the  bones  yield, 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS. 


FIG.  177. 


and  the  cephalotribe  sinks  into  tlic  cranium.  The  crushed  portion 
then  measures,  of  course,  no  more  than  the  thickness  of  the  blades, 
that  is  about  1J  inches.  This  is  necessarily  accompanied  by  some 
bulging  of  the  part  of  the  cranium  that  is  not  within  the  grasp  of 
the  instrument  (Fig.  177),  but  in  slight 
deformity  this  is  of  no  consequence,  and 
we  may  proceed  to  extraction,  waiting,  if 
possible,  for  a  pain,  and  drawing  down- 
wards in  the  axis  of  the  pelvic  outlet,  as 
in  forceps  delivery.  The  site  of  perfora- 
tion should  be  examined  to  see  that  no 
spiculse  of  bone  are  projecting  from  it,  and 
if  so  they  should  be  carefully  removed. 
In  such  cases  the  head  often  descends  at 
once,  and  with  the  greatest  ease.  Should 
it  not  do  so,  or  should  the  obstruction  be 
considerable,  a  quarter  turn  should  be 
given  to  the  handles  of  the  instrument, 
so  as  to  bring  the  crushed  portion  into 
the  narrowed  diameter,  and  the  uncrushed 
portion  into  the  wider  transverse  diameter. 
It  may  now  be  advisable  to  remove  the 
blades  carefully,  and  to  reintroduce  them 
with  the  same  precautions,  so  as  to  crush 
the  unbroken  portion  of  the  skull.  This 
adds  materially  to  the  difficulties  of  the 
case,  since  the  blades  have  a  tendency  to 
fall  into  the  deep  channel  already  made 
in  the  cranium,  and  so  it  is  by  no  means 
always  easy  to  seize  the  skull  in  a  new 
direction.  Before  reapplying  them,  if  the 
condition  of  the  patient  be  good  and  pains 
be  present,  it  may  be  well  to  wait  an  hour 
or  more,  in  the  hope  of  the  head  being 
moulded  and  pushed  down  into  the  pelvic 
cavity.  This  was  the  plan  adopted  by  Dubois,  and,  according  to 
Tarnier,  was  the  secret  of  his  great  success  in  the  operation.  Pajot's 
method  of  repeated  crushings,  in  the  greater  degrees  of  contraction, 
is  based  on  the  same  idea,  and  he  recommends  that  the  instrument 
should  be  reintroduced  at  intervals  of  two,  three,  or  four  hours, 
according  to  the  state  of  the  patient,  until  the  head  is  thoroughly 
crushed ;  no  attempts  at  traction  being  used,  and  expulsion  being 
left  to  the  natural  powers.  This,  he  says,  should  always  be  done 
when  the  contraction  is  below  2J  inches,  and  he  maintains  that  it  is 
quite  possible  to  effect  delivery  by  this  means  when  there  is  only  1J 
inches  in  the  antero-posterior  diameter.  The  repeated  introduction 
of  the  blades  in  this  fashion  must  necessarily  be  hazardous,  except 
in  the  hands  of  a  very  skilful  operator ;  and  I  believe  that  if  a 
second  application  fail  to  overcome  the  difficulty,  which  will  only  be 
very  exceptionally  the  case,  that  it  would  be  better  to  resort  to  the 
measures  presently  to  be  described. 


Footal  Head  crushed  liy  the 
Cephalotribe. 


496 


OBSTETRIC    OPERATIONS. 


FIG.  178.     FIG.  179. 


Should  we  elect  to  trust  to  the  craniotomy  forceps  for  extraction, 
one  blade  is  to  be  introduced  through  the  perforation,  and  the  other, 
in  apposition  to  it,  on  the  outside  of  the  scalp.  In  moderate  deformi- 
ties, traction  applied  during  the  pains  may  of  itself  suffice  to  bring 
down  the  head.  Should  the  obstruction  be  too  great  to  admit  of 
this,  it  is  necessary  to  break  down  and  remove  the  vault  of  the 
cranium.  For  this  purpose  Simpson's  cranioclast  answers  better 
than  any  other  instrument.  One  of  the  blades  is  passed  within  the 
cranium,  the  other,  if  possible,  between  the  scalp  and  the  skull,  and 
the  portion  of  bone  grasped  between  them  is  then  broken  oft';  this 
can  generally  be  accomplished  by  a  twisting  motion  of  the  wrist, 
without  using  much  force.  The  separated  portion  of  bone  is  then 
extracted,  the  greatest  care  being  taken  to  guard  the  maternal  struc- 
tures, during  its  removal,  by  the  fingers  of  the  left  hand.  The  in- 
strument is  then  applied  to  a  fresh  part  of  the  skull,  and  the  same 
process  repeated,  nntil  as  much  of  the  vault  of  the  cranium  as  may 
be  necessary  is  broken  up  and  removed. 

[The  craniotomy  forceps  chiefly  in  use  with  us  were  devised  by 
the  late  Prof.  Charles  D.  Meigs,  for  his  second  operation  upon  Mrs. 
Reybold,  of  Philadelphia,  in  1833,  and  have 
been  used  repeatedly  since,  either  as  tractors, 
or  for  reducing  the  size  of  the  foetal  head,  in 
cases  of  deformity  of  the  pelvis.2  Some  obste- 
tricians prefer  the  less  curved,  and  broader- 
bladed  instrument  of  Great  Britain,  as  a  trac- 
tor ;  but  for  the  general  purposes  of  picking 
away  the  cranial  bones,  and  drawing  down  the 
base  of  the  skull,  in  cases  of  extreme  pelvic 
deformity,  there  is  no  more  simple  appliance 
than  that  of  Dr.  Meigs. 

To  act  upon  an  oval  body  like  the  fcetal 
head,  Dr.  M.  was  obliged  to  prepare  two  forms 
of  forceps — straight  and  curved — to  be  used 
as  might  be  required,  according  to  the  part  of 
the  skull  to  be  broken  down,  or  drawn  upon. 
These  are  lightly  made,  serrated,  and  12| 
inches  in  length. — ED.] 

Advantages  of  bringing  down  the  Face  in 
Difficult  Cases. — Dr.  Braitton  Hicks1  has  con- 
clusively shown  that  in  difficult  cases,  after 
the  removal  of  the  cranial  vault,  the  proper 
procedure  is  to  bring  down  the  face;  since  the 
smallest  measurement  of  the  skull,  after  the 
removal  of  the  upper  part  of  the  cranium,  is  from  the  orbital  ridge 
to  the  alveolar  edge  of  the  superior  maxillary  bone.  This  alteration 
in  the  presentation  he  proposes  to  effect  by  a  small  blunt  hook,  made 

1  Obst.  Trans.,  vol.  vii. 

[2  The  illustration  given  is  taken  from  the  instruments  devised  by  Dr.  Mci;_r> 
as  an  improvement  upon  his  original  pattern,  and  will  be  seen  to  differ  from  that 
heretofore  given  in  American  obstetrical  publications. — ED.] 


Straight  Curved 

Craniotomy        Craniotomy 

Forceps.  Forceps. 


OPERATIONS    INVOLVING    DESTRUCTION    OF    FCETUS. 

for  the  purpose,  which  is  forced  into  the  orbit,  by  means  of  which 
the  face  is  made  to  descend.  Barnes  recommends  that  this  should 
be  done  by  fixing  the  craniotomy  forceps  over  the  forehead  and  face, 
and  making  traction  in  a  backward  direction,  so  as  to  get  the  face 
past  the  projecting  promontory  of  the  sacrum.  The  importance  of 
bringing  down  the  face  was  long  ago  pointed  out  by  Burns,  but  it 
had  been  lost  sight  of,  until  Hicks  again  drew  attention  to  it  in  the 
paper  referred  to.  In  the  class  of  cases  in  which  this  procedure  is 
valuable,  the  risk  to  the  maternal  passages,  from  the  removal  of 
fractured  portions  of  bone,  must  always  be  considerable,  and  it  is  of 
great  importance  not  only  to  preserve  the  scalp  as  entire  as  possible, 
so  as  to  protect  them,  but  to  use  the  utmost  possible  care  in  removing 
the  broken  pieces  of  bone. 

Extraction  of  the  Body. — When  the  extraction  of  the  head  has 
been  effected,  either  by  the  cephalotribe  or  the  craniotomy  forceps, 
there  is  seldom  much  difficulty  with  the  body.  By  traction  on  the 
head  one  of  the  axillae  can  easily  be  brought  within  reach,  and  if  the 
body  do  not  readily  pass,  the  blunt  hook  should  be  introduced*  and 
traction  made  until  the  shoulder  is  delivered.  The  same  can  then  be 
done  with  the  other  arm.  If  there  be  still  difficulty,  the  cephalotribe 
may  be  used  to  crushed  the  thorax.  The  body  is,  however,  so  com- 
pressible that  this  is  rarely  required. 

Embryotomy  where  Turning  is  Impossible. — There  only  remains  for 
us  to  consider  the  second  class  of  destructive  operations.  These  may 
be  necessary  in  long- neglected  cases  of  arm  presentation,  in  which 
turning  is  found  to  be  impracticable.  Here  fortunately  the  question 
of  killing  the  foetus  does  not  arise,  since  it  will,  almost  necessarily, 
have  already  perished  from  the  continuous  pressure.  We  have  two 
operations  to  select  from,  decapitation  and  evisceration. 

Decapitation. — The  former  of  these  is  an  operation  of  great  an- 
tiquity, having  been  fully  described  by  Celsus.  It  consists  in  sever- 
ing the  neck,  so  as  to  separate  the  head  from  the  body ;  the  body  is 
then  withdrawn  by  means  of  the  protruded  arm,  leaving  the  head  in 
utero  to  be  subsequently  dealt  with.  If  the  neck  can  be  reached 
without  great  difficulty — and,  in  the  majority  of  cases,  the  shoulder 
is  sufficiently  pressed  down  into  the  pelvis  to  render  this  quite  possi- 
ble— there  can  be  no  doubt,  that  it 'is  much  the  simpler  and  safer 
operation. 

Methods  of  Dividing  the  Neck. — The  whole  question  rests  on  the 
possibility  of  dividing  the  neck.  For  this  purpose  many  instruments 
have  been  invented.  The  one  generally  recommended  in  this  country 
is  known  as  Ramsbotham's  hook,  and  consists  of  a  sharply  curved 
hook,  with  an  internal  cutting  edge.  This  is  guided  over  the  neck, 
which  is  divided  by  a  sawing  motion.  There  is  often  considerable 
difficulty  in  placing  the  instrument  over  the  neck,  although,  if  this 
were  done,  it  would  doubtless  answer  well.  Others  have  invented 
instruments,  based  on  the  principle  of  the  apparatus  for  plugging 
the  nostrils,  by  means  of  which  a  spring  is  passed  round  the  neck, 
and  to  the  extremity  of  the  spring  a  short  cord,  or  the  chain  of  an 
e"craseur,  is  attached ;  the  spring  is  then  withdrawn  and  brings  the 


498  OBSTETRIC  OPERATIONS. 

chain  or  cord  into  position.  The  objection  to  any  of  these  appa- 
ratuses is,  that  they  are  unlikely  to  be  at  hand  when  required,  for 
few  practitioners  provide  themselves  with  costly  instruments  which 
they  may  never  require.  It  is  of  importance,  therefore,  that  we 
should  have  at  our  command  some  means  of  dividing  the  neck,  which 
is  available  in  the  absence  of  any  of  these  contrivances.  Dubois  re- 
commends for  this  purpose  a  strong  pair  of  blunt  scissors.  The  neck 
is  brought  as  low  as  possible  by  traction  on  the  prolapsed  arm,  and 
the  blades  of  the  scissors  guided  carefully  up  to  it.  By  a  series  of 
cautious  snipping  movements  it  is  then  completely  divided  from 
below  upwards.  This,  if  the  neck  be  readily  within  reach,  can  gen- 
erally be  effected  without  any  particular  difficulty.  Dr.  Kidd,  of 
Dublin,1  who  strongly  advocates  this  operation,  recommends  that  an 
ordinary  male  elastic  catheter,  strongly  curved  and  mounted  on  a  firm 
stilet,  or,  still  better,  on  a  uterine  sound,  should  be  passed  round  the 
neck.  Previous  to  introduction  a  cord  should  be  attached  to  the  ex- 
tremity of  the  catheter,  which  is  left  round  the  neck  when  it  is  with- 
drawn. By  means  of  this  cord  a  strong  piece  of  whipcord,  or  the 
wire  of  an  e"craseur,  can  easily  be  drawn  round  the  neck  and  used 
for  dividing  it.  The  former,  to  protect  the  maternal  structures, 
may  be  worked  through  a  speculum,  and  by  a  series  of  lateral 
movements  the  neck  is  easily  severed.  The  e"craseur,  however,  offers 
special  advantages,  since  it  entirely  does  away  with  any  risk  of  in- 
juring the  mother. 

Withdrawal  of  the  Body  and  Delivery  of  the  Head. — After  the  neck 
is  divided  the  remainder  of  the  operation  is .  easy.  The  body  is 
withdrawn  without  difficulty  by  the  arm,  and  we  then  proceed  to 
deliver  the  head.  By  abdominal  pressure  this,  in  most  cases,  can  be 
pushed  down  into  the  pelvis,  so  as  to  come  easily  within  reach  of 
the  cephalotribe,  which  is  by  far  the  best  instrument  for  extraction. 
Preliminary  perforation  is  not  necessary,  since  the  brain  can  escape 
through  the  severed  vertebral  canal.  The  secret  of  doing  this  easily 
is  to  fix  and  press  down  the  head  sufficiently  from  above,  otherwise 
it  would  slip  away  from  the  grasp  of  the  instrument.  The  perfora- 
tor and  craiiiotomy  forceps  may  be  used,  if  the  cephalotribe  be  not 
at  hand.  Perforation  is,  however,  by  no  means  always  easy,  on  ac- 
count of  the  mobility  of  the  head.  After  it  is  accomplished  one 
blade  of  the  craniotomy  forceps  is  passed  within  the  skull,  the  other 
externally,  and  the  head  slowly  drawn  down. 

Evisceration. — The  alternative  operation  of  evisceration  is  a  much 
more  troublesome  and  tedious  procedure,  and  should  only  be  used 
when  the  neck  is  inaccessible.  The  first  step  is  to  perforate  the 
thorax  at  its  most  depending  part,  and  to  make  as  wide  an  opening 
into  it  as  possible,  in  order  to  gain  access  to  its  contents.  Through 
this  the  thoracic  viscera  are  removed  piecemeal,  being  first  broken 
up  as  much  as  possible  by  the  perforator,  and  then,  the  diaphragm 
being  penetrated,  those  in  the  abdomen.  The  object  is  to  allow  the 
body  to  collapse,  and  the  pelvic  extremities  to  descend,  as  in  sponta- 

.    '  Dublin  Quart.  Journ.,  May,  1871. 


C.ESAREAN    SECTION.  499 

neons  evolution.  This  can  bo  much  facilitated  by  dividing  the  spinal 
column  with  a  strong  pair  of  scissors,  introduced  into  the  opening 
made  in  the  thorax,  so  that  the  body  may  be  doubled  up  as  on  a 
hinge.  Here  the  crotchet  may  find  a  useful  application,  for  it  can 
be  passed  through  the  abdominal  cavity,  and  fixed  on  some  point  in 
the  interior  of  the  child's  pelvis;  and  thus  strong  traction  can  be 
made  without  any  risk  of  injury  to  the  mother.  It  can  be  readily 
understood  that  this  process  is  so  lengthy  and  difficult  as  to  render 
it  probably  the  most  trying  of  obstetric  operations;  it  is  certainly 
inferior  in  every  respect  to  decapitation,  and  is  only  to  be  resorted 
to  when  that  is  impracticable. 

[In  seven  instances  of  impaction  of  the  foetus  in  a  transverse  posi- 
tion, in  the  United  States,  the  Cti?sarean  operation  has  been  per- 
formed, owing  to  great  difficulty  in  accomplishing  either  decapitation 
or  evisceration,  and  five  of  the  women  were  saved.  The  two  deaths 
were  from  exhaustion. — ED.] 


CHAPTER  VI. 

THE  CLESAREAN  SECTION — SYMPHYSEOTOMY — AND  LAPARO- 
ELYTEOTOMY. 

History. — The  Ccesarean  section  has  perhaps  given  rise  to  more 
discussion  than  any  other  subject  connected  with  midwifery,  and 
there  is  yet  much  difference  of  opinion  as  to  the  limits  of,  and  indica- 
tions for,  the  operation.  The  period  at  which  the  Cassarean  section 
was  first  resorted  to  is  not  known  with  accuracy.  It  seems  to  have 
been  practised  by  the  Greeks,  after  the  death  of  the  mother;  and 
Pliny  mentions  that  Scipio  Africanus  and  Manlius  were  born  in  this 
way.  The  name  of  Caesar  is  said  to  have  been  given  to  children  so 
extracted,  and  afterwards  to  have  been  assumed  as  a  family  patro- 
nymic. These  children  were  dedicated  to  Apollo;  whence  arose  the 
practice  of  things  sacred  to  that  god  being  taken  under  the  special 
protection  of  the  family  of  the  Caesars.  Many  celebrities  have  been 
supposed  to  owe  their  lives  to  the  operation;  among  the  rest  ^Escula- 
pius,  Julius  Caesar,  and  our  own  Edward  VI.  Regarding  the  two 
latter,  there  is  conclusive  proof  that  the  tradition  is  without  founda- 
tion. There  is  no  doubt  that  the  operation  was  constantly  practised 
on  women  who  had  died  at  an  advanced  period  of  pregnancy,  and 
indeed  it  has,  at  various  times,  been  enforced  by  law.  Thus  among 
the  Romans  it  was  decreed  by  Numa,  that  no  pregnant  woman  should 
be  buried  nntil  the  foetus  had  been  removed  by  abdominal  section. 
The  Italian  laws  also  made  it  necessary,  and  the  operation  has 


500  OBSTETRIC  OPERATIONS. 

always  received  the  strong  support  of  the  Roman  Church.  So  lately 
as  the  middle  of  the  eighteenth  century,  the  King  of  Sicily  sentenced 
to  death  a  physician  who  had  neglected  to  practise  it.  The  first 
authentic  case  in  which  the  operation  was  performed  on  a  living 
woman  occurred  in  1-191.  It  was  afterwards  practised  by  Nufer  in 
1500;  and  in  1581  Rousset  published  a  work  on  the  subject,  in  which 
a  number  of  successful  cases  were  related.  In  English  works  of  that 
time  it  is  not  alluded  to,  although  it  was  undoubtedly  performed  on 
the  Continent,  and  to  such  an  extent  that  its  abuse  became  almost 
proverbial.  We  have  evidence  in  Shakespeare,  however,  that  the 
operation  was  familiarly  known  in  this  country,  since  he  tells  us 
that — 

.     Macduff  was  from  his  mother's  womb 
1  Untimely  ripped. 

Pare'  and  Guillemeau,  amongst  the  writers  of  the  period,  were  noted 
for  their  hostility  to  the  operation,  while  others  equally  strongly 
upheld  it. 

In  this  country  it  has  scarcely  ever  been  performed  in  a  manner 
which  offers  even  the  faintest  hope  of  success.  It  has  been  looked 
upon  as  almost  necessarily  fatal  to  the  mother,  and  it  has,  therefore, 
been  delayed  until  the  patient  has  arrived  at  the  utmost  stage  of 
exhaustion.  For  example,  in  looking  over  the  records  of  British 
cases,  it  is  no  uncommon  thing  to  find  that  the  Csesarean  section  was 
resorted  to,  two,  three,  or  even  six  days  after  labor  had  begun,2  and 
when  the  patient  was  almost  moribund.  With  rare  exceptions  within 
the  last  few  years,  the  operation  has  been  performed  in  what  may  be 
called  a  hap-hazard  way.  In  many  cases  long  and  fruitless  attempts 
at  delivery  by  craniotomy  had  already  been  made,  so  that  the  pas- 
sages had  been  subjected  to  much  contusion  and  violence.  Little  or 
no  attempt  has  been  made  to  obviate  the  well-known  risks  of  ab- 
dominal operations ;  no  care  has  been  taken  to  prevent  blood  and 
other  fluids  finding  their  way  into  the  peritoneal  cavity,  and  no 
means  have  been  adopted  subsequently  to  remove  them.  It  is, 
therefore,  not  so  much  a  matter  of  surprise  that  the  mortality  has 
been  so  great,  but  rather  that  any  cases  have  recovered. 

Mortality. — From  what  wre  know  of  the  history  of  ovariotomy,  its 
early  fatality,  and  the  extreme  and  even  apparently  exaggerated 
precautions  which  are  essential  to  its  success,  it  is  fair  to  conclude 
that,  if  the  Cassarean  section  were  performed,  as  it  is  to  be  hoped  it 
always  will  be  in  future,  with  the  same  careful  attention  to  minute 
details  as  ovariotomy,  the  results  would  not  be  so  disastrous.  Making 
every  allowance  for  these  facts,  it  must  be  admitted  that  the  Caesa- 
rean  section  is  necessarily  almost  a  forlorn  hope ;  and  in  making 
these  observations  I  have  no  intention  of  contesting  the  well-estab- 
lished rule  of  British  practice,  that  it  is  not  admissible  as  an  opera- 

[!  The  word  "untimely"  we  have  always  regarded  as  proof  that  it  did  not  refer 
to  the  Ctesarean  section,  which  is  performed  during  labor.     It  more  likely  refers  to 
the  goring  of  a  bull  or  cow,  instances  of  which  are  upon  record. — ED.] 
*  See  Radford  on  Csesarean  Section,  p.  15. 


CJESAREAX    SECTION.  501 

tion  of  election,  and  must  only  be  resorted  to  when  delivery  per  vias 
naturales  is  impossible. 

Statistical  Returns  are  not  Reliable.  —  The  mortality,  as  given  in 
statistical  returns  from  various  sources,  differs  so  greatly  as  to  make 
them  but  little  reliable.  'Radford  tabulates  77  operations  performed 
in  this  country,  of  which  66,  or  85.71  per  cent.,  proved  fatal,  and  11 
or  14.28  per  cent.,  recovered.  Michaelis  and  Kayser  found  that  out 
of  258  and  338  operations,  54  and  61  per  cent,  respectively  were 
fatal.  These  include  operations  performed  under  all  sorts  of  condi- 
tions, even  when  the  patient  was  almost  moribund  ;  and  until  we  are 
in  possession  of  a  sufficient  number  of  cases  performed  under  con- 
ditions showing  that  the  result  is  obviously  due  to  the  operation— 
in  which  it  was  undertaken  at  an  early  period  of  labor,  and  performed 
with  a  reasonable  amount  of  care  —  it  is  obviously  impossible  to  arrive 
at  any  reliable  conclusions  as  to  the  mortality  of  the  operation.  That 
it  is  necessarily  hopeless  is  certainly  not  the  case,  and  we  know  that 
on  the  Continent,  where  it  is  resorted  to  much  oftener  and  earlier  in 
labor  than  in  this  country,  there  are  authentic  cases  in  which  it  has 
been  performed  twice,  thrice,  and  even,  in  one  instance,  four  times 
on  the  same  patient.  Kayser  thinks  that  a  second  operation  on  the 
same  patient  affords  a  better  prognosis  than  a  first,  probably  because 
peritoneal  adhesions,  resulting  from  the  first  operation,  have  shut  off 
the  general  abdominal  cavity  from  the  uterine  wound  ;  and  he  believes 
that  in  second  operations  the  mortality  is  not  more  than  29  per  cent. 

Results  to  the  Child.  —  The  mortality  of  the  children  likewise  cannot 
be  ascertained  from  statistical  returns,  since,  in  the  large  majority  of 
cases  in  which  dead  children  were  extracted,  the  result  had  nothing 
to  do  with  the  operation.  Indeed,  there  is  nothing  in  the  operation 
itself  which  can  reasonably  be  supposed  to  affect  the  child.  If,  there- 
fore, the  child  be  alive  when  the  operation  is  commenced,  there  is 
every  probability  of  its  being  extracted  alive  ;  and  Radford's  conclu- 
sion that,  "  the  risk  to  infants  in  Caesarean  births  is  not  much  greater 
than  that  which  is  contingent  on  natural  labor,  provided  correct  prin- 
ciples of  practice  are  adopted,"  probably  very  nearly  represents  the 
truth. 

Causes  requiring  the  Operation.  —  The  Cesarean  section  is  required 
when  there  is  such  defective  proportion  between  .the  child  and  the 
maternal  passages,  that  even  a  mutilated  foetus  cannot  be  extracted. 
This  in  by  far  the  greatest  number  of  cases  is  due  to  deformity  of 
the  pelvis  arising  from  rickets  or  mollities  ossium.  The  latter  may 
occur  in  a  patient  who  has  been  previously  healthy,  and  who  has 
given  birth  to  living  children.  It  is  a  more  common  cause  of  the 
extreme  varieties  of  deformity  than  rickets,  and  out  of  77  2British 
cases,  tabulated  by  Radford,  in  -13  the  deformity  was  produced  by 
osteomalacia,  and  in  14  only  by  rickets.  In  certain  cases  the  pelvis 
itself  may  be  of  normal  size,  but  has  its  cavity  obstructed  by  a  solid 

['  98  operations—  82  fatal,  16  recovered.     1868.  —  ED.] 

[2  Out  of  98,  there  were  46  deformed  by  osteomalacia  against  16  by  rickets.  — 
ED.] 

01-- 


l-KY  £10  I/;  US    L    -•  L'  KUIZO 
LC  b-    MillL  LLb\U  .  S.  ft.. 


502  OBSTETRIC  OPERATIONS. 

tumor  of  the  ovary,  of  the  uterus  itself,  or  one  growing  from  the 
pelvic  "\vall.  The  obstruction  may  also  depend  on  morbid  conditions 
of  the  maternal  soft  parts,  of  which  the  most  common  is  advanced 
malignant  disease  of  the  cervix.  Other  conditions  may,  however, 
render  it  essential.  Thus  Dr.  Newman1  records  a  case  in  which  he 
performed  the  operation  for  insurmountable  resistance  and  obstruc- 
tion of  the  cervix,  which  was  believed  at  the  time  to  be  malignant. 
The  patient  recovered,  and  was  subsequently  delivered  naturally, 
and  without  anything  abnormal  being  made  out.  This  renders  it 
probable  that  the  disease  was  not  malignant,  and  it  may  possibly 
have  been  an  extensive  inflammatory  exudation  into  the  tissues  of 
the  cervix,  subsequently  absorbed.  I  myself  was  present  at  a  Cassa- 
rean  section  performed  in  Calcutta  in  the  year  1857,  when  the  pelvis 
was  so  uniformly  blocked  up  with  exudation,  probably  due  to  exten- 
sive pelvic  cellulitis  or  haematocele,  that  the  operation  was  essential. 

Limits  of  Obstruction  justifying  the  Operation. — Different  accou- 
cheurs have  fixed  on  various  limits  for  the  operation.  Most  British 
authorities  are  of  opinion  that  it  need  not  be  resorted  to,  if  the 
smallest  diameter  of  the  pelvis  exceed  1|  inch.  This  question  has 
already  been  considered  in  discussing  craniotomy,  and  it  has  been 
shown  that  a  mutilated  foetus  may  be  drawn  through  a  pelvis  of  1J 
inch  antero-posterior  diameter,  provided  there  be  a  space  of  3  inches 
in  the  transverse  diameter.  If  sufficient  space  for  using  the  neces- 
sary instruments  do  not  exist,  the  Ceesarean  section  may  be  required, 
even  when  there  is  a  larger  antero-posterior  diameter  than  1J  inch. 
This  is  especially  likely  to  occur  when  we  have  to  do  with  deformity 
arising  from  mollities  ossium,  in  which  the  obstruction  is  in  the 
sides  and  outlet  of  the  pelvis,  the  true  conjugate  being  sometimes 
even  elongated.  On  the  Continent  the  Csesarean  section  is  constantly 
practised,  as  an  operation  of  election,  when  -the  smallest  diameter 
measures  from  2  to  2|  inches ;  and  when  the  child  is  known  to  be 
alive,  some  foreign  authors  recommend  it  when  there  are  as  much 
as  3  inches  in  the  antero-posterior  diameter.  In  this  country,  where 
the  life  of  the  child  is  most  properly  considered  of  secondary  import 
ance  to  the  safety  of  the  mother,  we  cannot  fix  one  limit  for  the  ope- 
ration when  the  child  is  living,  and  another  when  it  is  dead.  Nor,  I 
think,  can  we  admit  the  desire  of  the  mother  to  run  the  risk,  rather 
than  sacrifice  the  child,  as  a  justification  of  the  operation,  although 
this  is  laid  down  as  an  indication  by  Schroeder.2  Great  as  are  the 
dangers  attending  craniotomy  in  extreme  deformity,  there  can  be  no 
doubt  that  we  must  perform  it  whenever  it  is  practicable,  and  only 
resort  to  the  Ca3sarian  section  when  no  other  means  of  delivery  are 
possible. 

For  this  reason  I  think  it  unnecessary  to  discuss  the  question, 
whether  we  are  justified  in  destroying  the  foetus  in  several  successive 
pregnancies,  when  the  mother  knows  that  it  is  impossible  for  her  to 
give  birth  to  a  living  child.  Denman  was  the  first  to  question  the 

1  Obst.  Trans.,  vol.  iii.  p.  343. 

2  Manual  of  Midwifery,  p.  202. 


I 

C.ESAREAN    SECTION.  503 

advisability  of  repeating  craniotomy  on  the  same  patient.  Amongst 
modern  authors  Radford  takes  the  most  decided  view  on  this  point, 
and  distinctly  teaches  that  even  when  delivery  by  craniotomy  is  pos- 
sible, it  "can  be  justified  on  no  principle,  and  is  only  sanctioned  by 
the  dogma  of  the  schools,  or  by  usage,"  and  that,  therefore,  the 
Ciesarean  section  should  be  performed  with  the  view  of  saving  the 
child.  Doubtless  much  can  be  said  from  this  point  of  view;  but, 
nevertheless,  he  would  be  a  bold  man  who  would  deliberately  elect 
to  perform  the  Coesarean  section  on  such  grounds.1  It  is  to  be  hoped, 
however,  that  in  these  days  the  induction  of  premature  labor  or 
abortion  would  always  spare  us  the  necessity  of  deciding  so  delicate 
a  point. 

Post-mortem  Csesarean  Operation. — The  Ooesarean  section  may  also 
be  required  in  cases  in  which  death  has  occurred  during  pregnancy 
or  labor.  This  was  the  indication  for  which  it  was  first  employed,. 
and  it  has  constantly  been  performed  when  a  pregnant  woman  has 
died  at  an  advanced  period  of  utero-gestation.  There  is  no  doubt 
that  a  prompt  extraction  of  the  child  under  these  circumstances  has 
frequently  been  the  means  of  saving  its  life,  but  by  no  means  so  often 
as  is  generally  supposed.  Thus  Schwartz2  showed  that  out  of  107 
cases  not  one  living  child  was  extracted.  Villeneuve,3  however,  re- 
ports several  successful  cases,  in  4  of  which  the  operation  was  per- 
formed immediately  after  the  mother's  death,  in  5  others  at  periods 
varying  from  ten  minutes  to  half  an  hour. 

Want  of  Success  in  Post-mortem  Operation. — The  reason  that  the 
want  of  success  has  been  so  great,  is  doubtless  the  delay  that  must 
necessarily  occur  before  the  operation  is  resorted  to;  for,  inde- 
pendently of  the  fact  that  the  practitioner  is  seldom  at  hand  at  the 
moment  of  death,  the  very  time  necessary  to  assure  ourselves  that 
life  is  actually  extinct  will  generally  be  sufficient  to  cause  the  death 
of  the  foetus.  Considering  the  intimate  relations  between  the  mother 
and  child,  we  can  scarcely  expect  vitality  to  remain  in  the  latter 
more  than  a  quarter,  or  at  the  outside,  half  an  hour,  after  it  has 
ceased  in  the  former.  The  recorded  instances  in  which  a  living  child; 
were  extracted  ten,  twelve,  and  even  forty  hours  after  death,  were 
most  probably  cases  in  which  the  mother  fell  into  a  prolonged  trance 
or  swoon,  during  the  continuance  of  which  the  child  must  have  been 
removed.  A  few  authentic  cases,  however,  are  known  in  which 
there  can  be  no  reasonable  doubt  that  the  operation  was  performed 
successfully  several  hours  after  the  mother  was  actually  dead.  An 
often -quoted  and  interesting  example  is  that  of  the  Princess  of 
Schwartzenburgh,  who  perished  one  evening  in  a  fire  at  Paris,  and 
from  whose  body  a  living  infant  is  said  to  have  been  removed  on  the 
morning  of  the  following  day ;  the  authenticity  of  this  case,  however,, 
is  open  to  grave  doubt. 

['  This  was  done  twice  in  the  case  of  Mrs.  Reybold,  of  Philadelphia,  after  she 
had  twice  been  delivered  by  craniotomy  under  Dr.  Meigs,  who  declined  destroying 
any  more  children  for  her. — ED.] 

*  Monat.  f.  Geburt,  suppl.  vol.,  1861,  p.  121. 

3  Operat.  Ca;sar.  Apres  la  Mort,  Paris.  1862. 


I 

504  OBSTETRIC  OPERATIONS. 

Since,  then,  there  is  a  chance,  however  slight,  of  saving  the  child's 
life,  we  are  bound  to  perform  the  operation,  even  when  so  much  time 
has  elapsed  as  to  render  the  chances  of  success  extremely  small.  It 
might  be  considered  almost  superfluous  to  insist  on  the  necessity  of 
assuring  ourselves  of  the  mother's  death  before  commencing  the  neces- 
sary incisions ;  but,  unfortunately,  numerous  instances  are  known  in 
which  mistakes  in  diagnosis  have  been  made,  and  in  which  the  first 
steps  of  the  operation  have  shown  that  the  mother  was  still  alive. 
The  operation  should,  therefore,  always  be  performed  with  the  same 
care  and  caution  as  if  the  mother  were  living.  If  death  have 
occurred  during  labor,  some  have  advised  version  as  a  preferable 
alternative.  This  can  only  be  resorted  to,  with  any  hope  of  success, 
if  the  passages  be  in  a  condition  to  admit  of  delivery  with  rapidity ; 
otherwise  the  delay  required  for  dilatation,  even  when  forcibly 
accomplished,  and  the  drawing  of  the  child  through  the  pelvis,  will 
be  almost  necessarily  fatal.  The  only  argument  in  favor  of  version 
is,  that  it  is  less  painful  to  the  friends ;  and,  if  they  manifest  a  decided 
objection  to  the  Caesarean  section,  there  can  be  no  reason  why  an 
attempt  to  save  the  child  in  this  way  should  not  be  made. 

Causes  of  Death  after  Csesarean  Section. — The  causes  of  death  after 
the  Caesarean  section  may,  speaking  generally,  be  classed  under  four 
principal  heads ;  hemorrhage,  peritonitis  and  metritis,  shock,  and 
septicaemia.  [And  exhaustion  from  long  delay. — ED.]  These  are 
pretty  much  the  same  as  those  following  ovariotomy,  and  the  resem- 
blance between  the  two  operations  is  so  great  that  modern  experience 
as  to  the  best  mode  of  performing  ovariotomy,  as  well  as  regards  the 
after  treatment,  may  be  taken  as  a  guide  in  the  management  of  cases 
of  Caesarean  section. 

Hemorrhaye  is  Frequent,  although  Seldom  Fatal. — Hemorrhage  to 
an  alarming  extent  is  a  frequent  complication,  although  seldom  the 
cause  of  death.  Thus  out  of  88  operations,  the  particulars  of  which 
have  been  carefully  noted,  severe  hemorrhage  occurred  in  14,  6  of 
which  terminated  successfully,  and  in  4  only  could  the  fatal  result  be 
ascribed  to  the  loss  of  blood.  In  1  of  these  the  source  of  the  hemor- 
rhage is  not  mentioned,  in  another  it  came  from  the  wound  in  the 
abdominal  wall,  and  in  the  other  2  from  the  uterine  incision  being 
made  directly  over  the  placenta.  In  neither  of  the  2  latter  was  the 
loss  of  blood  immediately  fatal ;  for  it  was  checked  by  uterine  con- 
traction, and  only  recurred  after  many  hours  had  elapsed.  The 
divided  uterine  sinuses,  and  the  open  mouths  of  the  vessels  at  the 
placental  site,  are  the  most  common  sources  of  hemorrhage. 

Means  of  avoiding  the  Risk. — Much  may  be  done  to  diminish  the 
risk  of  bleeding,  but  even  with  every  precaution,  it  must  be  a  source 
of  danger.  Hemorrhage  from  the  abdominal  wall  may  be  best 
prevented  by  making  the  incision  as  nearly  as  possible  in  the  line 
of  the  linea  alba,  so  as  not  to  wound  the  epigastric  arteries,  and  by 
tying  any  bleeding  vessels  as  we  proceed.  The  principal  loss  of 
blood  will  be  met  with  in  dividing  the  uterus;  and  this  will  be 
greatest  when  the  incision  is  near  or  over  the  placental  site,  where 
the  largest  vessels  are  met  with.  We  are  recommended  to  ascertain 


C^SAREAX    SECTION. 

the  position  of  the  placenta  by  auscultation,  and  thus,  if  possible,  to 
avoid  opening  the  uterus  near  its  insertion.  But  even  if  we  admit 
the  placental  souffle  to  be  a  guide  to  its  situation,  if  the  placenta  be 
attached  to  the  anterior  walls  of  the  uterus,  a  knowledge  of  its  posi- 
tion would  not  always  enable  us  to  avoid  opening  the  uterus  in  its 
immediate  vicinity.  We  must,  in  the  event  of  its  lying  under  the 
incision,  rather  hope  to  control  the  hemorrhage  by  removing  it  at 
once  from  its  attachments,  and  rapidly  emptying  the  uterus.  When 
the  child  has  been  removed  there  may  be  a  large  escape  of  .blood; 
but  this  will  generally  be  stopped  by  the  contraction  of  the  uterus, 
in  the  same  manner  as  after  natural  labor.  Should  contraction  not 
take  place,  the  uterus  may  be  firmly  grasped  for  the  purpose  of 
exciting  it.  This  plan  is  advocated  by  Winckel,  who  had  a  large 
experience  in  the  operation;  and  by  using  free  compression  in  this 
way,  and  making  a  point  of  not  closing  the  wound  until  the  uterus 
is  firmly  contracted,  he  has  never  met  with  any  inconvenience  from 
hemorrhage.  If  bleeding  continue,  styptic  applications  may  be  used, 
as  in  a  case  reported  by  Hicks,  who  was  obliged  to  swab  out  the 
uterine  cavity  with  a  solution  of  perchloride  of  iron. 

Peritonitis  and  Metritis  are  frequent  Causes  of  Death. — Among  the 
most  frequent  causes  of  death  are  peritonitis  and  metritis.  Kayser 
attributes  the  fatal  result  to  them  in  77  out  of  123  unsuccessful  cases. 

The  mere  division  of  the  peritoneum  will  not  account  for  the  fre- 
quency of  this  complication,  since  its  occurrence  is  considerably  more 
frequent  than  after  ovariotomy,  in  which  the  injury  to  the  peritoneum 
is  quite  as  great,  and  indeed  greater,  if  we  take  into  account  the 
adhesions  which  have  to  be  divided  or  torn  in  that  operation. 

The  division  of  the  uterus  must  be  regarded  as  one  source  of  this 
danger.  Dr.  West  lays  great  stress  on  its  unfavorable  condition 
after  delivery  for  reparative  action.  He  believes  that  the  process  of 
involution  or  fatty  degeneration  which  commences  in  the  muscular 
fibres  previous  to  delivery,  renders  them  peculiarly  unfitted  to  cica- 
trize ;  and  he  points  out  that,  on  post-mortem  examination,  the  edges 
of  the  incision  have  been  found  dry,  of  unhealthy  color,  gaping,  and 
showing  no  tendency  to  heal.  On  this  account  Hicks  and  others 
have  operated  ten  days  or  more  before  the  full  period  of  labor,  in 
the  hope  that  the  risk  from  this  source  might  be  avoided.  It  is  by 
no  means  certain,  however,  that  the  change  in  the  uterine  fibres  is 
the  cause  of  the  wound  not  healing,  and  involution  will  commence 
at  once  when  the  uterus  is  emptied,  even  if  the  full  period  of  preg- 
nancy have  not  arrived.  As  a  point  of  ethics,  moreover,  it  is  question- 
able if  we  are  justified  in  anticipating  the  date  of  so  dangerous  an 
operation,  even  by  a  few  weeks,  unless  the  benefit  to  be  derived  is 
very  decided  indeed. 

Escape  of  Lochia  and  other  Fhiids  into  the  Peritoneal  Cavity. — One 
important  cause  of  peritonitis  is  the  escape  of  the  lochia  through  the 
uterine  incision  into  the  cavity  of  the  peritoneum,  which  there  de- 
compose and  act  as  an  unfailing  source  of  irritation.  This  may  be 
prevented,  to  a  great  extent,  by  seeing  that  the  os  uteri  is  patulous, 
so  as  to  afford  a  channel  for  the  escape  of  discharges,  and  by  closing 
33 


506  OBSTETRIC  OPERATIONS. 

the  uterine  wound  by  sutures.  In  addition  there  is  the  danger 
arising  from  blood  and  liquor  amnii  escaping  into  the  peritoneum, 
and  subsequently  decomposing.  There  is  little  evidence  that  "la 
toilette  du  peritoine,"  on  which  ovariotomists  now  lay  so  much 
stress,  has  ever  been  particularly  attended  to  in  Csesarean  operations. 

The  Unhealthy  Condition  of  the  Patient  is  the  Chief  Source  of  Danger. 
— The  chief  predisposing  cause  of  these  inflammations,  however,  must 
be  looked  for  in  the  condition  of  the  patient,  just  as  asthenic  inflam- 
mation in  ovariotomy  is  most  frequently  met  with  in  those  whose 
general  health  is  broken  down  by  the  long  continuance  of  the  disease. 
We  are  fully  justified,  therefore,  in  assuming  that  peritonitis  and 
metritis  will  be  more  likely  to  occur  after  the  Cnesarean  section  when 
that  operation  has  been  unnecessarily  delayed,  and  when  the  patient 
is  exhaused  by  a  protracted  labor.  In  proof  of  this  we  find  that,  in 
the  large  proportion  of  the  cases  above  mentioned,  peritonitis  oc- 
curred when  the  operation  was  performed  under  unfavorable  con- 
ditions. 

Septicaemia. — The  sources  of  septicaemia  are  abundantly  evident, 
not  the  least,  probably,  being  absorption  by  the  open  vessels  in  the 
uterine  incision. 

Nervous  Shock. — The  last  great  danger  is  general  shock  to  the  ner- 
vous system.  In  Kayser's  123  cases,  30  of  the  deaths  are  referred 
to  this  cause.  In  the  large  majority  of  these  the  patient  was  pro- 
foundly exhausted  before  the  operation  was  begun.  It  is  in  predis- 
posing to  these  nervous  complications,  that  we  should,  d  priori,  expect 
that  vacillation  and  delay  would  be  most  hurtful ;  and  in  operating 
when  the  patient's  strength  is  still  unimpaired,  we  afford  her  the  best 
chance  of  bearing  the  inevitable  shock  of  an  operation  of  such  mag- 
nitude. 

Secondary  Dangers. — In  addition  a  few  cases  have  been  lost  from 
accidental  complications,  which  are  liable  to  occur  after  any  serious 
operation,  and  which  do  not  necessarily  depend  on  the  nature  of  the 
procedure. 

Danger  to  Child  from  Portions  of  its  Body  being  caught  l>y  the  Con- 
tracting Uterus. — There  is  only  one  source  of  danger,  special  to  the 
child,  which  is  worthy  of  attention.  As  the  infant  is  being  removed 
from  the  cavity  of  the  uterus,  the  muscular  parietes  sometimes  con- 
tract with  great  rapidity  and  force,  so  as  to  seize  and  retain  some 
part  of  its  body.  [A  rapid  delivery  by  the  feet,  will  usually  prevent 
this,  but  a  pair  of  forceps  should  be  at  hand  for  the  emergency. — ED.] 
This  occurred  in  2  of  Dr.  Kadford's  cases,  and  in  1  of  them  it  is 
stated  that  "  the  child  was  vigorously  alive  when  first  taken  hold  of, 
but,  from  the  length  of  time  occupied  in  extracting  the  head,  it  be- 
came so  enfeebled  as  to  show  only  slight  signs  of  life,"  and  subse- 
quently all  attempts  at  resuscitation  failed.  I  have  myself  seen  the 
head  caught  in  this  way,  and  so  forcibly  retained  that  a  second  in- 
cision was  required  to  release  it.  In  Dr.  Badford's  cases  the  placenta 
happened  to  be  immediately  under  the  incision,  and  he  attributes  the 
inordinate  and  rapid  contraction  of  the  uterus  to  its  premature  sepa- 
ration. It  is  difficult  to  believe  that  this  was  more  than  a  coinci- 


C./ESAREAN    SECTION.  507 

dence,  because  the  contraction  does  not  take  place  until  the  greater 
part  of  the;  child's  body  has  been  withdrawn,  and  because  numerous 
cases  are  recorded  in  which  the  uterus  was  opened  directly  over  the 
placenta,  or  in  which  it  was  lying  loose  and  detached,  in  none  of 
which  this  accident  occurred.  The  true  explanation  may,  I  think, 
be  found  in  the  varying  irritability  of  the  uterus  in  different  cases. 

Irrespective  of  the  risk  of  portions  of  the  child  being  caught  and 
detained,  rapid  contraction  is  a  distinct  advantage,  since  the  danger 
of  hemorrhage  is  thereby  much  diminished.  Serious  consequences 
may  be  best  avoided  by  removing,  when  practicable,  the  head  and 
shoulders  of  the  child  first,  or  by  employing  both  hands  in  extrac- 
tion, one  being  placed  near  the  head,  the  other  seizing  the  feet. 
Either  of  these  methods  is  preferable  to  the  common  practice  of  lay- 
ing hold  of  the  part  that  may  chance  to  lie  most  conveniently  near 
the  line  of  incision.  If  this  point  were  properly  attended  to,  al- 
though the  detention  of  the  lower  extremities  might  occasionally 
occur,  the  life  of  the  child  would  not  be  imperilled. 

The  preparation  of  the  patient  for  the  operation  should  seriously  oc- 
cupy the  attention  of  the  practitioner,  and  this  is  the  more  essential, 
since  almost  all  patients  requiring  the  Coesarean  section  are  in  a 
wretchedly  debilitated  condition.  [This  is  the  case  in  England,  where 
osteomalacia  prevails,  but  it  is  exceptional  in  most  cases  in  our  own 
land,  in  the  early  period  of  labor. — ED.]  If  the  patient  be  not  seen 
until  she  is  actually  in  labor,  of  course  this  is  out  of  the  question. 
But  this  will  rarely  be  the  case,  since  the  deformed  condition  of  the 
patient  must  generally  have  attracted  attention.  Every  possible 
means  should  be  taken,  therefore,  when  practicable,  to  improve  the 
general  health  by  abundance  of  simple  and  nourishing  diet,  plenty 
of  fresh  air,  and  suitable  tonics  (amongst  which  preparations  of  iron 
should  occupy  a  prominent  place),  while  the  state  of  the  secretions, 
the  bowels,  skin,  and  kidneys,  should  be  specially  attended  to. 
Whenever  it  is  possible  a  large,  airy  apartment  should  be  selected 
for  the  operation,  which  should  never  be  done  in  a  hospital,  if  other 
arrangements  be  practicable.  These  details  may  seem  trivial  and 
unnecessary ;  but  to  insure  success  in  so  hazardous  an  under- 
taking, no  care  can  be  considered  superfluous,  and  probably  the 
want  of  attention  to  such  points  has  had  much  to  do  with  increasing 
the  mortality. 

Question  of  Time  to  be  Selected  for  the  Operation. — The  question 
arises  whether  we  should  operate  before  labor  has  commenced.  By 
selecting  our  own  time,  as  some  have  advised,  we  certainly  have  the 
advantage  of  operating  under  the  most  favorable  conditions,  instead 
of  possibly  hurriedly.  There  are,  however,  numerous  advantages  in 
waiting  until  spontaneous  uterine  action  has  commenced,  which 
seem  to  me  to  more  than  counterbalance  the  advantages  of  choosing 
our  own  time.  Prominent  among  these  is  the  partial  opening  of  the 
os  uteri,  so  as  to  afford  a  channel  for  the  escape  of  the  lochia,  and 
the  certainty  of  active  contraction  of  the  uterus,  to  arrest  hemor- 
rhage. Barnes  recommends  that  premature  labor  should  be  first  in- 
duced,  and  then  the  operation  performed.  This  seems  to  me  to 


508  OBSTETRIC  OPERATIONS. 

introduce  a  needless  element  of  complexity ;  and  besides,  in  cases  of 
great  deformity,  it  is  by  no  means  always  easy  to  reach  the  cervix 
with  the  view  of  bringing  on  labor.  All  needful  arrangements 
should  be  made,  so  as  to  avoid  hurry  and  excitement  when  the 
operation  is  commenced,  and  we  may  then  wait  patiently  until  labor 
has  fairly  set  in. 

The  Administration  of  Anaesthetics. — The  operation  itself  is  simple. 
The  patient  should  be  placed  on  a  table,  in  a  good  light,  and  with 
the  temperature  of  the  room  raised  to  about  65°. l  Chloroform  has 
so  frequently  been  followed  by  severe  vomiting,  that  it  is  probably 
better  not  to  administer  it.  For  the  same  reason  Mr.  Spencer  Wells 
has  long  given  up  using  it  in  ovariotomy,  and  finds  that  chloro- 
methyl  answers  admirably.  In  one  or  two  cases  local  anaesthesia 
has  been  used,  by  means  of  two  spray  producers  acting  simulta- 
neously; and  this  plan,  if  the  patient  have  sufficient  fortitude  to 
dispense  with  general  anaesthesia,  has  the  further  advantage  of 
stimulating  the  uterus  to  powerful  contraction. 

Description  of  the  Operation. — The  incision  should  be  made  as  much 
as  possible  in  the  line  of  the  linea  alba,  so  as  to  avoid  wounding  the 
epigastric  arteries.  On  account  of  the  deformity,  the  configuration 
of  the  abdomen  is  often  much  altered,  and  some  have  advised  that 
the  incision  should  be  made  oblique  or  transverse,  and  on  the  most 
prominent  part  of  the  abdomen.  The  risk  of  hemorrhage  being  thus 
much  increased,  the  practice  is  not  to  be  recommended.  The  incision, 
commencing  a  little  above  the  umbilicus,  is  carried  down  for  about 
three  inches  below  it.  The  skin  and  muscular  fibres  are  carefully 
divided,  layer  by  layer,  until  the  shining  surface  of  the  peritoneum 
is  reached,  and  any  bleeding  vessels  should  be  secured  as  we  proceed. 
A  small  opening  is  now  made  in  the  peritoneum,  which  should  be 
laid  open  along  the  whole  length  of  the  incision,  upon  two  fingers  of 
the  left  hand  introduced  as  a  guide.  Before  incising  the  uterus  an 
assistant  should  carefully  support  it  in  a  proper  position,  and  push 
it  forward  by  the  hands  placed  on  either  side  of  the  incision,  so  as  to 
bring  its  surface  into  apposition  with  the  external  wound,  and  pre- 
vent the  escape  of  the  intestines.  If  we  have  reason  to  believe  that 
the  placenta  is  situated  anteriorly,  we  may  incise  the  uterus  on  one 
or  other  side;  otherwise  the  line  of  incision  should  be  as  nearly  as 
possible  central.  The  substance  of  the  uterus  is  next  divided  until 
the  membranes  are  reached,  which  are  punctured,  and  divided  in  the 
same  way  as  the  peritoneum.  The  uterine  incision  should  be  of  the 
same  length  as  that  in  the  abdomen,  and  it  should  not  be  made  too 
near  the  fundus;  for  not  only  is  that  part  more  vascular  than  the 
body  of  the  uterus,  but  wounds  in  that  situation  are  more  apt  to 
gape,  and  do  not  cicatrize  so  favorably.  After  the  uterus  is  opened, 
Dr.  "Winckel  recommends  that  the  fingers  of  an  assistant  should  be 
placed  in  the  two  terminal  angles  of  the  wound,  so  that  the  ends  of 
the  incision  may  be  hooked  up,  and  brought  into  close  apposition 
with  the  abdominal  opening.  By  this  means  he  prevents  not  only 

['  The  temperature  usually  recommended  in  this  country  is  75°  to  80°. — ED,] 


C^ESAREAX    SECTION.  509 

the  escape  of  blood  and  liquor  amnii  into  the  cavity  of  the  perito- 
neum, but  also  the  protrusion  of  the  abdominal  viscera. 

Removal  of  the  Child. — The  child  should  now  be  carefully  removed, 
the  head  and  shoulders  being  taken  out  (if  possible)  at  first;  the 
placenta  and  membranes  are  afterwards  extracted.  Should  the  pla- 
centa be  unfortunately  found  immediately  under  the  incision,  a  con- 
siderable' loss  of  blood  is  likely  to  take  place,  which  can  only  be 
checked  by  removing  it  from  its  attachments,  and  concluding  the 
operation  as  rapidly  as  possible. 

Importance  of  securing  Uterine  Contraction. — As  soon  as  the  child 
and  the  secundines  have  been  extracted,  the  sooner  the  uterus  con- 
tracts the  better.  It  will  usually  do  so  of  itself,  but  should  it  remain 
lax  and  flabby,  it  should  be  pressed  and  stimulated  by  the  hand. 
We  are  specially  warned  against  handling  the  uterus  by  Ramsbotham 
and  others;  but  there  seems  no  valid  reason  why  we  should  not 
restrain  hemorrhage  in  this  way,  as  after  a  natural  labor.  The 
intervention  of  the  abdominal  parietes,  in  their  lax  condition  after 
delivery,  can  make  very  little  difference  between  the  two  cases. 

Closure  of  the  Uterine  and  Abdominal  Wounds} — The  advisability 
of  closing  the  uterine  wound  by  sutures  is  a  mooted  point.  The 
balance  of  evidence  is  certainly  in  favor  of  this  practice,  as  tending 
to  prevent  the  escape  of  the  lochia  into  the  peritoneal  cavity.  Inter- 
rupted sutures  of  silver  wire  or  carbolized  gut2  may  be  used,  and  cut 
short ;  or,  as  successfully  practised  by  Spencer  Wells,  a  continuous 
silk  suture  may  be  applied,  one  end  being  passed  through  the  os  into 
the  vagina,  by  which  it  is  subsequently  withdrawn.  Before  closing 
the  uterine  wound  one  or  two  fingers  should  be  passed  through  the 
cervix,  to  insure  its  being  patulous.  A  free  escape  of  the  lochia  in 
this  direction  is  of  great  consequence,  and  Winckel  even  advises  the 
placing  of  a  strip  of  lint,  soaked  in  oil,  in  the  os,  so  as  to  keep  up  a 
free  exit  for  the  discharge. 

A  point  of  great  importance,  and  not  sufficiently  insisted  on,  is 
the  advisability  of  not  closing  the  abdominal  wound  until  we  are 
thoroughly  satisfied  that  hemorrhage  is  completely  stopped,  since 
any  escape  of  blood  into  the  peritoneum  would  very  materially  lessen 
the  chances  of  recovery.  In  a  successful  case  reported  by  Dr.  New- 
man,3 the  wound  was  not  closed  for  nearly  an  hour.  Before  doing 
so  all  blood  and  discharges  should  be  carefully  removed  from  the 
peritoneal  cavity,  by  clean  soft  sponges  dipped  in  warm  water.  The 
abdominal  wound  should  be  closed  from  above  downwards,  by  harelip 
pins,  wire  or  silk  sutures,  which  should  be  inserted  at  a  distance  of 
an  inch  from  each  other,  and  passed  entirely  through  the  abdominal 
walls  and  the  peritoneum,  at  some  little  distance  from  the  edges  of 

[!  Sutures,  mostly  of  silver,  have  been  used  in  fifteen  operations  out  of  one  hundred 
and  one,  in  the  United  States.  We  regard  their  use  as  invaluable,  where  the  wound 
gapes  from  uterine  inertia. — ED.] 

[2  Carbolized  catgut  has  been  used  in  the  United  States  but  once,  and  then  failed. 
Even  when  treble-knotted,  the  suture  is  apt  to  become  untied.  The  experience  of 
the  last  ten  years  in  Europe  has  caused  it  to  be  almost  universally  abandoned. — ED.] 

3  Obst.  Trans.,  vol.  viii. 


510  OBSTETRIC  OPERATIONS. 

the  incision,  so  as  to  bring  the  two  surfaces  of  the  peritoneum  into 
contact.  By  this  means  we  insure  the  closure  of  the  peritoneal 
cavity,  the  opposed  surfaces  adhering  with  great  rapidity.  The  sur- 
face of  the  wound  is  then  covered  with  pads  of  folded  lint,  kept  in 
position  by  long  strips  of  adhesive  plaster,  and  the  whole  covered 
with  a  soft  flannel  belt. 

Subsequent  Management. — Into  the  subsequent  treatment  it  is  un- 
necessary to  enter  at  any  length,  since  it  must  be  regulated  by  general 
principles,  each  symptom  being  met  as  it  arises.  It  has  been  cus- 
tomary to  administer  opiates  freely  after  the  operation ;  but  they 
seem  to  have  a  tendency  to  produce  sickness  and  vomiting,  and  ought 
not  to  be  exhibited  unless  pain  or  peritonitis  indicate  that  they  are 
required.  In  fact,  the  treatment  should  in  no  way  differ  from  that 
usual  after  ovariotomy,  and  the  principles  that  should  guide  us  will 
be  best  shown  by  the  following  quotation  from  Mr.  Spencer  Wells's 
description  of  that  operation :  "  The  principles  of  after-treatment 
are — to  obtain  extreme  quiet,  comfortable  warmth,  and  perfectly 
clean  linen  to  the  patient;  to  relieve  pain  by  warm  applications  to 
the  abdomen,  and  by  opiate  enemas;  to  give  stimulants  when  they 
are  called  for  by  failing  pulse  or  other  signs  of  exhaustion ;  to  relieve 
sickness  by  ice,  or  iced  drinks;  and  to  allow  plain,  simple,  but 
nourishing  food.  The  catheter  must  be  used  every  six  or  eight 
hours,  until  the  patient  can  move  without  pain.  The  sutures  are  re- 
moved on  the  third  day,  unless  tympanitic  distension  of  the  stomach 
or  intestines  endanger  re-opening  of  the  wound.  In  such  circum- 
stances they  may  be  left  for  some  days  longer.  The  superficial 
sutures  may  remain  until  union  seems  quite  firm." 

Substitutes  for  the  Csesarean  Section;  Symphyseotomy. — Bearing  in 
mind  the  great  mortality  attending  the  Caesarean  section,  it  is  not 
surprising  that  obstetricians  should  have  anxiously  considered  the 
possibility  of  devising  a  substitute,  which  should  afford  the  mother 
a  better  chance  of  recovery.  The  first  proposal  of  the  kind  was  one 
from  which  great  results  were  at  first  anticipated.  In  1768  Sigault, 
then  a  student  of  medicine  in  Paris,  suggested  symphyseotomy,  which 
consists  in  the  division  of  the  symphysis  pubis,  with  the  view  of 
allowing  the  pubic  bones  to  separate  sufficiently  to  admit  of  the 
passage  of  the  child.  Although  at  first  strongly  opposed,  it  was  sub- 
sequently ardently  advocated  by  many  obstetricians,  and  was  often 
performed  on  the  Continent,  and  in  a  few  cases  in  this  country. 

The  Operation  is  Admitted  to  be  Useless.— It  is  generally  admitted 
that  it  is  quite  impossible  to  make  this  a  substitute  for  the  Coesarean 
section,  since  the  utmost  gain  which  even  a  wide  separation  of  the 
symphysis  pubis  would  give  woulcl  be  altogether  insufficient  to  admit 
of  the  passage  of  even  a  mutilated  foetus.  Dr.  Churchill  concludes 
that,  even  if  were  possible  to  separate  it  to  the  extent  of  four  inches, 
we  should  only  have  an  increase  of  from  four  lines  to  half  an  inch  ifa. 
the  antero-posterior  diameter,  in  which  the  obstruction  is  generally 
most  marked.  In  the  lesser  degrees  of  deformity  this  might  possibly 
be  sufficient  to  allow  the  foetus  to  pass;  but  the  risk  of  the  operation 


C^ESAREAN    SECTION.  511 

itself,  and  the  subsequent  ill  effects,  altogether  centra-indicate  it  in 
cases  of  this  description. 

Laparo-Elytrotomy. — A  far  more  promising  operation  is  one  which 
was  originally  suggested  by  Jorg  and  Ritgen,  in  1820,  under  the 
name  of  Gastro-Elytrotomy,  but  which,  in  the  then  defective  state  of 
abdominal  surgery,  scarcely  received  attention,  and  has  not  even 
been  alluded  to  in  any  of  our  standard  obstetric  works.  It  has  re- 
cently been  reconsidered  by  Professor  Thomas,  of  New  York,1  who 
suggests  for  it  the  name  of  Laparo-Elytrotomy,  and  it  has  now  been 
performed  five  times  in  America.  In  two  out  of  these  cases  the 
mother  was  in  articulo  mortis,  but  the  remaining  three  mothers  re- 
covered ;  and,  out  of  ten,  five  children  were  born  alive.  This  is  a 
remarkable  result,  and,  at  the  least,  entitles  this  operation  to  the 
most  earnest  attention  of  the  profession.  Should  future  cases  show 
anything  like  the  same  success  it  will  be  the  duty  of  accoucheurs  to 
adopt  this  procedure  instead  of  the  almost  inevitably  fatal  Cassareau 
section.2 

Object  of  the  Operation  and  its  Advantages. — In  this  operation  it  is 
proposed  to  divide  the  vagina  at  its  juncture  with  the  cervix,  this 
being  reached  by  an  incision  extending  from  the  symphysis  pubis  to 
the  anterior  superior  spine  of  the  ilium.  The  loosely-attached  peri- 
toneum is  then  raised  up,  and  the  child  removed  through  the  os  uteri 
by  turning,  and  extracted  through  the  opening  in  the  abdomen.  It 
must  be  at  once  apparent  that  the  chief  dangers  of  the  Cossarean 
section  are  obviated ;  for  the  peritoneal  cavity  is  not  opened  (and, 
therefore  the  risk  of  peritonitis  is  much  lessened),  there  is  no  escape 
of  blood  into  the  peritoneum,  and  the  uterus  itself  is  not  incised.  The 
operation,  as  described  and  performed  by  Thomas,  is  as  follows : — 

1st.  An  incision  is  made  extending  from  the  symphysis  pubis  to 
the  anterior  superior  spine  of  the  ilium,  dividing  the  thickness  of  the 
abdominal  walls  until  the  peritoneum  is  reached. 

2d.  The  peritoneum  is  lifted  up  by  means  of  the  fingers,  or  by 
metal  retractors,  so  as  to  admit  of  the  juncture  of  the  vagina  and 
uterus  being  reached.  So  far  the  operation  is  precisely  that  which 
is  practised  by  surgeons  for  the  ligature  of  the  iliac  arteries,  and 
offers  no  particular  difficulties. 

3d.  The  vagina  is  made  to  protrude  in  the  wound  by  means  of  a 
metal  sound,  introduced  through  the  vulva,  and  is  divided  to  a  suffi- 
cient extent. 

4th.  This  will  allow  the  cervix  to  be  reached,  and  it  is  drawn  into 
the  iliac  fossa  by  a  blunt  hook  passed  into  it,  while  the  fundus  uteri 
is  depressed  by  an  assistant  in  an  opposite  direction.  If  the  os  uteri 
be  sufficiently  open  (and  if  possible  it  should  have  been  previously 
dilated  with  caoutchouc  bags),  the  hand  is  passed  into  the  uterus,  and 
the  child  removed  by  turning. 

1  Laparo-Elytrotomy,  a  substitute  for  the  Caesarean  Section :  read  before  the  New 
York  Academy  of  Medicine,  March  6,  1878. 

2  [A  very  careful  canvass  of  the  State  of  Louisiana,  carried  on  for  some  years, 
shows  18  Caesarean  operations  with  14  women  saved. — ED.] 


512  OBSTETRIC  OPERATIONS. 

In  the  American  cases  no  special  difficulty  was  met  with  in  the 
performance  of  the  operation,  although  in  some  of  them  the  perito- 
neum was  thickened  and  united  to  the  neighboring  parts  by  antece- 
dent inflammation.  It  is  worthy  of  notice  that  in  none  of  them  was 
there  any  hemorrhage  of  consequence,  although  the  large  vascular 
supply  to  the  vagina  naturally  renders  that  one  of  the  most  serious 
risks  which  we  have  to  apprehend. 

No  one  who  has  seen  much  of  ovariotomy  could  reasonably  hold 
that  there  is  anything  in  this  procedure  incompatible  with  success. 
Whether  subsequent  experience  will  justify  the  hopes  that  Dr. 
Thomas  holds  out,  remains  to  be  seen.  Of  course,  all  that  can  now 
be  said  of  it  is,  that  the  operation  is  theoretically  sufficiently  simple, 
and  that  it  offers  a  possible  way  of  removing  the  child,  without  some 
of  the  gravest  risks  of  the  Cassarean  section.  Should  hemorrhage 
occur,  it  would  probably  be  quite  within  control,  either  by  ligatures, 
or,  as  Thomas  suggests,  by  passing  a  metallic  speculum  either  through 
the  abdominal  wound  or  the  vagina,  and  applying  through  it  the 
actual  cautery  or  the  perchloride  of  iron.  No  difficulty  need  be 
anticipated  in  retracting  the  peritoneum  to  a  sufficient  extent,  for  in 
pregnancy  that  membrane  is  unusually  ample,  and  much  more  loose 
in  its  attachments  than  in  the  non-pregnant  state. 

[This  operation,  devised  by  Eitgen  and  Physick,  and  put  into  suc- 
cessful practice  by  Thomas  and  Skene,  may  possibly  prove  much 
less  fatal  than  gastro-hysterotomy  has  in  England,  but  we  have 
grave  doubts  as  to  its  adaptation  to  the  rostrate  pelvis  of  malacos- 
teon,  which  must  materially  interfere  with  delivery  through  the  vagi- 
nal incision. — ED.] 

[The  Caesarean  operation  in  our  own  country,  with  all  its  disad- 
vantages in  a  newly  settled  and  sparsely  inhabited  land,  has  been  so 
much  more  successful  than  in  Great  Britain,  that  we  are  inclined  to 
regard  it  with  much  less  dread  of  consequences  than  is  done  by 
English  obstetricians.  We  are  very  apt  in  the  United  States  to  be 
influenced  by  the  medical  experiences  of  the  Old  World,  and  to  cal- 
culate risks  in  operations  by  their  collected  statistics,  when  a  careful 
collation  at  home,  would  show  very  different  results.  In  no  one 
operation  perhaps,  is  there  a  more  marked  difference,  than  is  to  be 
found  in  the  records  of  gastro-hysterotomy  in  England  and  America. 
This  is  due  to  several  causes,  which  are  greatly  in  our  favor.  1.  We 
have  the  advantages  of  a  dry  climate.  2.  Osteomalacia,  the  adult 
bone-softening,  so  prevalent  among  child-bearing  women  of  the  Old 
World,  and  so  fruitful  a  cause  of  pelvic  deformity,  does  not  prevail 
here,  and  has  in  no  instance  in  America  been  the  cause  of  difficulty, 
which  has  made  the  Csesarean  section  a  necessity.  3.  To  the  exist- 
ence of  this  disease  we  attribute  much  of  the  want  of  success  in 
Great  Britain.  4.  We  have  no  beer-drinking  peasant  women  to 
operate  upon,  than  whom  worse  subjects  for  surgery  can  scarcely  be 
found.  5.  We  do  not  operate  upon  a  woman  with  the  feeling,  that 
in  all  human  probability  she  is  much  more  likely  to  die  than  recover, 
and  on  this  account,  make  her  case  almost  hopeless  by  long  delay,  or 
by  various  fruitless  and  exhausting  expedients  to  avoid  the  resort  to 


CyESAREAN    SECTION.  513 

what  has  been  denominated  "the  forlorn  Jtope."  We  have  in  many 
instances  failed  through  delay;  "but  a  comparison  made  between 
timely  English  and  American  operations  is  very  largely  in  our  favor.1 
By  means  of  a  long-continued  research,  and  an  extensive  correspond- 
ence, we  have  collected  the  records  of  108  American  Cresarean  cases, 
101  of  them  being  in  the  United  States.  Fifty  one  of  the  108  women 
were  saved  alive,  and  45  out  of  the  101 ;  the  proportionate  mortality 
in  the  second  instance,  being  increased  by  the  fact,  that  38  of  the  101 
cases  had  never  been  published,  such  operations  having  been  fatal 
in  the  proportion  of  two  to  one  saved.  Published  cases,  as  a  rule, 
show  much  the  most  favorable  side  of  the  question,  our  own  giving 
a  mortality  of  only  36  per  cent,  against  one  of  68  per  cent.,  in  those  ob- 
tained by  direct  correspondence.  We  believe  that  our  statistics  more 
fully  represent  the  truth  with  regard  to  gastro-hysterotomy  in  our 
country  than  those  of  any  other  land  yet  published;  although  after 
nine  years'  search  we  feel  that  the  work  is  still  imperfect. 

What  most  concerns  us,  is  to  determine  the  true  danger  of  the 
operation  in  the  United  States,  when  performed  with  due  regard  to 
time  and  condition.  This  we  can  approach  in  a  measure  by  noting 
the  result  in  24  cases  where  the  section  was  made  early  in  labor; 
there  were  18  women  and  21  children  saved. 

Seventeen  operations  performed  upon  eight  women  resulted  favor- 
ably in  fourteen  instances ;  one  died  from  the  third  operation  and  two 
from  the  second. 

We  are  inclined  to  believe,  that  if  timely  performed,  and  with 
due  skill  and  care,  the  Caesarean  operation  in  our  country  is  not  as 
dangerous  as  eraniotomy  in  pelves  having  a  conjugate  diameter  of 
2|  inches  or  less.  This  was  the  opinion  of  the  late  Dr.  Parry,2  and 
our  own  observations  have  fully  confirmed  his  views.  In  this  city 
the  Caesarean  operation  has  been  performed  four  times  with  a  loss  of 
two  women,  all  the  children  being  alive  at  the  last  accounts. 

There  is  no  reason  why  our  obstetricians  should  stand  in  awe  of 
this  operation  if  they  are  prompt  in  deciding  and  acting,  so  as  to 
give  both  mother  and  child  the  best  possible  prospect  of  life.  It 
should  always  be  remembered,  that  the  danger  does  not  lie  so  much 
in  incising  the  uterus  per  se,  as  in  making  the  incision,  when  this 
organ  has  been  rendered  susceptible  to  inflammatory  action  by  its 
prolonged  efforts  at  expulsion  and  by  exhaustion  on  the  part  of  the 
patient.  Ovariotomists  by  their  repeated  successes,  have  prepared  the 
way  for  a  more  hopeful  view  of  gastro-hysterotomy  and  of  laparotomy 
for  the  purpose  of  delivery  in  rupture  of  the  uterus  and  abdominal 
pregnancy;  and  there  is  reason  to  believe  that  in  time  all  these 
operations  will  be  performed  with  an  encouraging  hope  of  success. — 
ED.] 

1  See  Harris  on  Gastro-hysterotomy,  Am.  Jour.  Med.  Sci.,  April,  1878,  p.  324. 

2  Amer.  Journ.  of  Obst.,  vol.  v.,  p.  644. 


514  OBSTETRIC  OPERATIONS. 


CHAPTER  VII. 

THE   TRANSFUSION   OF   BLOOD. 

THE  transfusion  of  blood  in  desperate  and  apparently  hopeless 
cases  of  hemorrhage,  offers  a  possible  means  of  rescuing  the  patient 
which  merits  careful  consideration.  It  has  again  and  again  attracted 
the  attention  of  the  profession,  but  has  never  become  popularized  in 
obstetric  practice.  The  reason  of  this  is  not  so  much  the  inherent 
defects  of  the  operation  itself — for  quite  a  sufficient  number  of  suc- 
cessful cases  are  recorded  to  make  it  certain  that  it  is  occasionally  a 
most  valuable  remedy — but  the  fact  that  the  operation  has  been  con- 
sidered a  delicate  and  difficult  one,  and  that  it  has  been  deemed 
necessary  to  employ  complicated  and  expensive  apparatus,  which  is 
never  at  hand  when  a  sudden  emergency  arises.  Whatever  may  be 
the  difference  of  opinion  about  the  value  of  transfusion,  I  think  it 
must  be  admitted  that  it  is  of  the  utmost  consequence  to  simplify 
the  process  in  every  possible  way,  and  it  is  above  all  things  neces- 
sary to  show  that  the  steps  of  the  operation  are  such  as  can  be  readily 
performed  by  any  ordinarily-qualified  practitioner,  and  that  the  ap- 
paratus is  so  simple  and  portable  as  to  make  it  easy  for  any  obstetri- 
cian to  have  it  at  hand.  There  are  comparatively  few  who  would 
consider  it  worth  while  to  carry  about  with  them,  in  ordinary  every- 
day work,  cumbrous  and  expensive  instruments  which  may  never  be 
required  in  a  life-long  practice ;  and  hence  it  is  not  unlikely  that,  in 
many  cases  in  which  transfusion  might  have  proved  useful,  the  op- 
portunity of  using  it  has  been  allowed  to  slip.  Of  late  years  the 
operation  has  attracted  much  attention,  the  method  of  performing  it 
has  been  greatly  simplified,  and  I  think  it  will  be  easy  to  prove  that 
all  the  essential  apparatus  may  be  purchased  for  a  few  shillings,  and 
in  so  portable  a  form  as  to  take  up  little  or  no  room ;  so  that  it 
may  be  always  carried  in  the  obstetric  bag  ready  for  any  possible 
emergency. 

The'  history  of  the  operation  is  of  considerable  interest.  In  Villari's 
"  Life  of  Savonarola  "  it  is  said  to  have  been  employed  in  the  case  of 
Pope  Innocent  VIII.,  in  the  year  1492,  but  I  am  not  aware  on  what 
authority  the  statement  is  made.  The  first  serious  proposals  for  its 
performance  do  not  seem  to  have  been  made  until  the  latter  half  of 
the  seventeenth  century.  It  was  first  actually  performed  in  France, 
by  Denis,  of  Montpellier,  although  Lower,  of  Oxford,  had  previously 
made  experiments  on  animals  which  satisfied  him  that  it  might  be 
undertaken  with  success.  In  November,  1667,  some  months  after 
Denis's  case,  he  made  a  public  experiment  at  Arundel  House,  in 
which  twelve  ounces  of  sheep's  blood  were  injected  into  the  veins  of 
a  healthy  man,  who  is  stated  to  have  been  very  well  after  the  opera- 


THE    TRANSFUSION    OF    BLOOD.  515 

tion,  wliicli  must,  therefore,  have  proved  successful.  These  nearly 
simultaneous  cases  gave  rise  to  a  controversy  as  to  priority  of  inven- 
tion, which  was  long  carried  on  with  much  bitterness. 

The  idea  of  resorting  to  transfusion  after  severe  hemorrhage  does 
not  seem  to  have  been  then  entertained.  It  was  recommended  as  a 
means  of  treatment  in  various  diseased  states,  or  with  the  extrava- 
gant hope  of  imparting  new  life  and  vigor  to  the  old  and  decrepit. 
The  blood  of  the  lower  animals  only  was  used ;  and,  under  these  cir- 
cumstances, it  is  not  surprising  that  the  operation,  although  practised 
on  several  occasions,  was  never  established  as  it  might  have  been  had 
its  indications  been  better  understood. 

From  that  time  it  fell  almost  entirely  into  oblivion,  although  ex- 
periments and  suggestions  as  to  its  applicability  were  occasionally 
made,  especially  by  Dr.  Harwood,  Professor  of  Anatomy  at  Cam- 
bridge, who  published  a  thesis  on  the  subject  in  the  year  1785.  He, 
however,  never  carried  his  suggestions  into  practice,  and,  like  his  pre- 
decessors, only  proposed  to  employ  blood  taken  from  the  lower 
animals.  In  the  year  1824  Dr.  Blundell  published  his  well-known 
work,  entitled  "  Researches,  Physiological  and  Pathological,"  which 
detailed  a  large  number  of  experiments ;  and  to  that  distinguished 
physician  belongs  the  undoubted  merit  of  having  brought  the  subject 
prominently  before  the  profession,  and  of  pointing  out  the  cases  in 
which  the  operation  might  be  .performed  with  hopes  of  success. 
Since  the  publication  of  this  work,  transfusion  has  been  regarded  as 
a  legitimate  operation  under  special  circumstances ;  but,  although  it 
has  frequently  been  performed  with  success,  and  in  spite  of  many  in- 
teresting monographs  on  the  subject,  it  has  never  become  so  estab- 
lished, as  a  general  resource  in  suitable  cases,  as  its  advantages  would 
seem  to  warrant.  Within  the  last  few  years  more  attention  has  been 
paid  to  the  subject,  and  the  writings  of  Panum,  Martin,  and  de  Belina, 
abroad,  and  of  Higginson,  McDonnell  Hicks,  and  Aveling  at  home, 
amongst  many  others,  have  thrown  much  light  on  many  points  con- 
nected with  the  operation,  and  it  is  to  be  hoped  that  the  committee 
appointed  by  the  Obstetrical  Society,  in  their  forthcoming  report, 
may  still  more  increase  our  knowledge. 

Nature  and  Object  of  the  Operation. — Transfusion  is  practically  only 
employed  in  cases  of  profuse  hemorrhage  connected  with  labor,  al- 
though it  has  been  suggested  as  possibly  of  value  in  certain  other 
puerperal  conditions,  such  as  eclampsia,  or  puerperal  fever.  Theo- 
retically it  may  be  expected  to  be  useful  in  such  diseases ;  but,  inas- 
much as  little  or  nothing  is  known  of  its  practical  effects  in  these 
diseased  states,  it  is  only  possible  here  to  discuss  its  use  in  cases  of 
excessive  hemorrhage.  Its  action  is  probably  twofold.  1st,  the 
actual  restitution  of  blood  which  has  been  lost.  2d,  the  supply  of  a 
sufficient  quantity  of  blood  to  stimulate  the  heart  to  contraction,  and 
thus  to  enable  the  circulation  to  be  carried  on  until  fresh  blood  is 
formed.  The  influence  of  transfusion  as  a  means  of  restoring  lost 
blood  must  be  trivial,  since  the  quantity  required  to  produce  an  effect 
is  generally  very  small  indeed,  and  never  sufficient  to  counter- 
balance that  which  has  been  lost.  Its  stimulant  action  is  no  doubt 


516  OBSTETRIC  OPERATIONS. 

of  far  more  importance ;  and  if  the  operation  be  performed  before 
the  vital  energies  are  entirely  exhausted,  the  effect  is  often  most 
marked. 

Use  of  Blood  taken  from  the  Lower  Animals . — In  the  earliest  opera- 
tions the  blood  used  was  always  that  of  the  lower  animals,  generally 
of  the  sheep.  Dr.  Blundell  believed  that  such  blood  could  not  be 
employed  with  success.  Kecent  cases,  such  as  those  published  by 
Keene,  who  used  lamb's  blood  in  12  cases,1  have  conclusively  proved 
this  idea  to  be  erroneous.  Brown-Se'quard  has  shown  that  Blundell's 
experiments  with  animal  blood  failed,  partly  because  he  used  too 
large  a  quantity  and  injected  too  quickly,  and  partly  because  he  used 
blood  too  rich  in  carbonic  acid  and  too  poor  in  oxygen.  He  has 
shown  that  the  success  of  the  operation  must  depend  to  a  great  ex- 
tent on  these  points,  and  that  blood,  containing  sufficient  carbonic 
acid  to  be  black,  proves  directly  poisonous,  unless  it  is  injected  in 
very  small  quantity,  and  with  great  slowness.  Although,  then,  it 
is  certain  that  the  blood  of  some  of  the  lower  animals,  especially  of 
those  in  which  the  corpuscles  are  of  less  size  than  in  man,  as  in  sheep, 
can  be  employed  with  safety,  still  the  operation,  of  late  years,  has 
been  almost  always  performed  with  human  blood  alone,  and,  for 
many  obvious  reasons,  is  always  likely  to  be  so. 

Difficulties  from  Coagulation  of  Fibrine — The  great  practical  diffi- 
culty in  transfusion  has  always  been  the  coagulation  of  the  blood 
very  shortly  after  it  has  been  removed  from  the  body.  When  fresh 
drawn  blood  is  exposed  to  the  atmosphere,  the  fibrine  commences  to 
solidify  rapidly,  generally  in  from  three  to  four  minutes,  sometimes 
much  sooner.  It  is  obvious  that  the  moment  fibrination  has  com- 
menced the  blood  is,  ipso  facto,  unfitted  for  transfusion,  not  only  be- 
cause it  can  be  no  longer  passed  readily  through  the  injecting  appa- 
ratus, but  because  of  the  great  danger  of  propelling  small  masses  of 
fibrine  into  the  circulation,  and  thus  causing  embolism.  Hence,  if  no 
attempt  be  made  to  prevent  this  difficulty,  it  is  essential,  no  matter 
what  apparatus  is  used,  to  hurry  on  the  operation  so  as  to  inject  be- 
fore fibrination  has  begun.  This  is  a  fatal  objection,  for  there  is  no 
operation  in  the  whole  range  of  surgery  in  which  calmness  and  de- 
liberation are  so  essential,  the  more  so  as  the  surroundings  of  the 
patient  in  these  unfortunate  cases  are  such  as  to  tax  the  presence 
of  mind  and  coolness  of  the  practitioner  and  his  assistants  to  the 
utmost. 

Methods  of  Obviating  Coagulation. — All  the  recent  improvements 
have  had  for  their  object  the  avoidance  of  coagulation,  and  practi- 
cally this  has  been  effected  in  one  of  three  ways.  1st,  by  immediate 
transfusion  from  arm  to  arm,  without  allowing  the  blood  to  be  ex- 
posed to  the  atmosphere,  according  to  the  methods  proposed  by 
Aveling  and  Roussel.  [Direct  tubular  transfusion  from  arm  to  arm, 
is  pictured  in  Heister's  Surgery,  London,  1768,  p.  336. — ED.]  2d,  by 
adding  to  the  blood  certain  chemical  reagents  which  have  the  pro- 
perty of  preventing  coagulation.  3d,  removal  of  the  fibrine  entirely, 

1  London  Med.  Record,  Dec.  31,  1873. 


THE    TRANSFUSION    OF    BLOOD.  517 

by  promoting  its  coagulation  and  straining  the  blood,  so  that  the 
liquor  sanguinis  and  blood  corpuscles  alone  are  injected. 

Inasmuch  as  the  success  of  the  operation  altogether  depends  on 
the  method  adopted,  it  will  be  well,  before  going  further,  to  consider 
briefly  the  advantages  and  disadvantages  of  each  of  these  plans. 

Immediate  Transfusion.- — -1.  The  method  of  immediate  transfusion 
has  been  brought  prominently  before  the  profession  by  Dr.  Aveling, 
who  has  invented  an  ingenious  apparatus  for  performing  it.  The 
apparatus  consists  essentially  of  a  miniature  Higginson's  syringe, 
without  valves,  and  with  a  small  silver  canula  at  either  end.  One 
canula  is  inserted  into  the  vein  of  the  person  supplying  blood,  the 
other  into  a  vein  of  the  patient,  and  by  a  peculiar  manipulation  of 
the  syringe,  subsequently  to  be  described,  the  blood  is  carried  from 
one  vein  into  the  other.  It  must  be  admitted  that,  if  there  were  no 
practical  difficulties,  this  instrument  would  be  admirable,  and  it  is 
therefore  not  surprising  that  it  should  have  met  with  so  much  favor 
from  the  profession.  I  cannot  but  think,  however,  that  the  opera- 
tion is  not  so  simple  as  it  at  first  sight  appears,  and  that  therefore  it 
wants  one  of  the  essential  elements  required  in  any  procedure  for 
performing  transfusion.  One  of  my  objections  is,  that  it  is  by  no 
means  easy  to  work  the  apparatus  without  considerable  practice. 
Of  this  I  have  satisfied  myself  by  asking  members  of  my  class  to 
work  it  after  reading  the  printed  directions,  and  finding  that  they 
are  not  always  able  to  do  so  at  once.  Of  course  it  may  be  said  that 
it  is  easy  to  acquire  the  necessary  manipulative  skill ;  but,  when  the 
necessity  for  transfusion  arises,  there  is  no  time  left  for  practising 
with  the  instrument,  and  it  is  essential  that  an  apparatus,  to  be  uni- 
versally applicable,  should  be  capable  of  being  used  immediately, 
and  without  previous  experience.  Other  objections  are  the  necessity 
of  several  assistants,  the  uncertainty  of  there  being  a  sufficient  circu- 
lation of  blood  in  the  veins  of  the  donor  to  afford  a  constant  supply, 
and  the  possibility  of  the  whole  apparatus  being  disturbed  by  rest- 
lessness or  jactitation  on  the  part  of  the  patient.  For  these  reasons, 
it  seems  to  me  that  this  plan  of  immediate  transfusion  is  not  so 
simple,  nor  so  generally  applicable,  as  defibrination.  Still,  it  is  im- 
possible not  to  recognize  its  merits,  and  it  is  certainly  well  worthy 
of  further  study  and  investigation. 

Another  method  of  immediate  transfusion  is  that  recommended 
by  Koussel,1  whose  apparatus  has  recently  attracted  considerable 
attention.  It  possesses  many  undoubted  advantages,  and  is,  beyond 
doubt,  a  valuable  addition  to  our  means  of  performing  the  opera- 
tion. It  has,  however,  the  great  disadvantage  of  being  costly  and 
complicated,  and  hence  I  do  not  believe  that  it  is  likely  to  come  into 
general  use. 

Addition  of  Chemical  Ayents  to  Prevent  Coagulation. — 2.  The  second 
plan  for  obviating  the  bad  effects  of  clotting  is  the  addition  of  some 
substance  to  the  blood  which  shall  prevent  coagulation.  It  is  well 
known  that  several  salts  have  this  property,  and  the  experiments 

1  Obstetrical  Transactions,  vol.  xviii. 


518  OBSTETRIC  OPERATIONS. 

made  in  the  case  of  cholera  patients  prove  that  solutions  of  some  of 
them  may  be  injected  into  the  venous  system  without  injury.  This 
method  has  been  specially  advocated  by  Dr.  Braxton  Hicks,  who 
uses  a  solution  of  three  ounces  of  fresh  phosphate  of  soda  in  a  pint 
of  water,  about  six  ounces  of  which  are  added  to  the  quantity  of 
blood  to  be  injected.  He  has  narrated  4  cases1  in  which  this  plan 
was  adopted  successfully,  so  far  as  the  prevention  of  coagulation  was 
concerned.  It  certainly  enables  the  operation  to  be  performed  with 
deliberation  and  care,  but  it  is  somewhat  complicated ;  and  it  may 
often  happen  that  the  necessary  chemicals  are  not  at  hand.  A  further 
objection  is  the  bulk  of  fluid  which  must  be  injected,  and  there  is 
reason  to  believe  that  this  has,  in  some  cases,  seriously  embarrassed 
the  heart's  action,  and  interfered  with  the  success  of  the  operation. 
In  many  of  the  successful  cases  of  transfusion  the  amount  of  blood 
injected  has  been  very  small,  not  more  than  two  ounces.  Dr. 
Eichardson  proposes  to  prevent  coagulation  by  the  addition  of 
liquor  ammonite  to  the  blood,  in  the  proportion  of  two  minims, 
diluted  with  twenty  minims  of  water,  to  each  ounce  of  blood. 

Deftbrination  of  the  Blood. — 3.  The  last  method,  and  the  one  which, 
on  the  whole,  I  believe  to  be  the  simplest  and  most  effectual,  is  defi- 
brination.  It  has  been  chiefly  practised  in  this  country  by  Dr. 
McDonnell,  of  Dublin,  who  has  published  several  very  interesting 
cases  in  which  he  employed  it,  and  abroad  by  Martin,  of  Berlin ;  de 
Belina,  of  Paris  [and  James  G.  Allen,  of  Philadelphia. — ED.].  The 
process  of  removing  the  fibrine  is  simple  in  the  extreme,  and  occu- 
pies a  few  minutes  only.  Another  advantage  is  that  the  blood  to 
be  transfused  may  be  prepared  quietly  in  an  adjoining  apartment,  so 
that  the  operation  may  be  performed  with  the  greatest  calmness  and 
deliberation,  and  the  donor  is  spared  the  excitement  and  distress 
which  the  sight  of  the  apparently  moribund  patient -is  apt  to  cause, 
and  which,  as  Dr.  Hicks  has  truly  pointed  out,  may  interfere  with 
the  free  flow  of  blood.  The  researches  of  Panum,  Brown-Sequard, 
and  others,  have  proved  that  the  blood  corpuscles  are  the  true  vivi- 
fying element,  and  that  defibrinated  blood  acts  as  well,  in  every 
respect,  as  that  containing  fibrine.  It  has  been  proved  that  the 
fibrine  is  reproduced  within  a  short  time,2  and  the  whole  tendency 
of  modern  research  is  to  regard  it,  not  as  an  essential  element  of  the 
blood,  but  as  an  excrementitious  product,  resulting  from  the  degra- 
dation of  tissue,  which  may,  therefore,  be  advantageously  removed. 
Another  advantage  derived  from  defibrination  is,  that  the  corpuscles 
are  freely  exposed  to  the  atmosphere,  oxygen  is  taken  up,  and  car- 
bonic acid  given  off,  and  the  dangers  which  Brown-Sequard  has 
shown  to  arise  from  the  use  of  blood  containing  too  much  carbonic 
acid  are  thereby  avoided.  There  can  be,  therefore,  no  physiological 
objection  to  the  removal  of  the  fibrine,  which,  moreover,  takes  away 
all  practical  difficulty  from  the  operation.  The  straining  to  which 
the  defibrinated  blood  is  subjected  entirely  prevents  the  possibility 

1  Guy's  Hosp.  Reports,  vol.  xiv. 

2  Panum,  Virchow's  Arch.,  vol.  xxvii 


THE    TRANSFUSION    OF    BLOOD.  519 

of  even  the  most  minute  particle  of  fibrine  being  contained  in  the 
injected  fluid;  the  risk  from  embolism  is,  therefore,  less  than  in  any 
of  the  other  processes  already  referred  to.  My  own  experience  of 
this  plan  is  limited  to  3  cases,  but  in  2  it  answered  so  well  that  I  can 
conceive  no  reasonable  objection  to  it.  I  should  be  inclined  to  say 
that  transfusion,  thus  performed,  is  amongst  the  simplest  of  surgical 
operations — an  opinion  which  the  experience  of  McDonnell  and 
others  fully  confirms. 

Statistical  Results. — The  number  of  cases  of  transfusion  are  perhaps 
not  sufficient  to  admit  of  completely  reliable  conclusions.  It  is  cer- 
tain, however,  that  transfusion  has  often  been  the  means  of  rescuing 
the  patient  when  apparently  at  the  point  of  death,  and  after  all  other 
means  of  treatment  had  failed.  Professor  Martin  records  57  cases, 
in  43  of  which  transfusion  was  completely  successful,  and  in  7  tem- 
porarily so;  while  in  the  remaining  7  no  reaction  took  place.  Dr. 
Higginson,  of  Liverpool,  has  had  15  cases,  10  of  which  were  success- 
ful. Figures  such  as  these  are  encouraging,  and  they  are  sufficient 
to  prove  that  the  operation  is  one  which  at  least  offers  a  fair  hope  of 
success,  and  which  no  obstetrician  would  be  justified  in  neglecting, 
when  the  patient  is  sinking  from  the  exhaustion  of  profuse  hemor- 
rhage. It  is  to  be  hoped  also  that  further  experience  may  prove  it 
to  be  of  value  in  other  cases,  in  which  its  use  has  been  suggested, 
but  not,  as  yet,  put  to  the  test  of  experiment. 

Possible  Dangers  of  the  Operation. — The  possible  risks  of  the  opera- 
tion would  seem  to  be  the  danger  of  injecting  minute  particles  of 
fibrine  which  form  emboli,  or  bubbles  of  air,  or  of  overwhelming  the 
action  of  the  heart  by  injecting  too  rapidly,  or  in  too  great  quantity. 
These  may  be,  to  a  great  extent,  prevented  by  careful  attention  to 
the  proper  performance  of  the  operation,  and  it  does  not  clearly 
appear,  from  the  recorded  cases,  they  have  ever  proved  fatal.  We 
must  also  bear  in  mind  that  transfusion  is  seldom  or  ever  likely  to 
be  attempted  until  the  patient  is  in  a  state  which  would  otherwise 
almost  certainly  preclude  the  hope  of  recovery,  and  in  which,  there- 
fore, much  more  hazardous  proceedings  would  be  fully  justified. 

Cases  Suitable  for  Transfusion. — The  cases  suitable  for  transfusion 
are  those  in  which  the  patient  is  reduced  to  an  extreme  state  of 
exhaustion  from  hemorrhage  during  or  after  labor  or  miscarriage, 
whether  by  the  repeated  losses  of  placenta  prsevia,  or  the  more 
sudden  and  profuse  flooding  of  post-partum  hemorrhage.  The  opera- 
tion will  not  be  contemplated  until  other  and  simpler  means  have 
been  tried  and  failed,  or  until  the  symptoms  indicate  that  life  is  on 
the  verge  of  extinction.  If  the  patient  should  be  deadly  pale  and 
cold,  with  no  pulse  at  the  wrist,  or  one  that  is  scarcely  perceptible ; 
if  she  be  unable  to  swallow,  or  vomits  incessantly;  if  she  lie  in  an 
unconscious  state;  if  jactitation,  or  convulsions,  or  repeated  fainting 
should  occur;  if  the  respiration  be  laborious,  or  very  rapid  and 
sighing;  if  the  pupil  do  not  act  under  the  influence  of  light;  it  is 
evident  that  she  is  in  a  condition  of  extreme  danger,  and  it  is,  under 
such  circumstances,  that  transfusion,  performed  sufficiently  soon, 
offers  a  fair  prospect  of  success.  It  does  not  necessarily  follow  be- 


5'20  OBSTETRIC    OPERATIONS. 

cause  one  or  other  of  these  symptoms  is  present,  that  there  is  no 
chance  of  recovery  under  ordinary  treatment,  and  indeed  it  is  within 
the  experience  of  all,  that  patients  have  rallied  under  apparently  the 
most  hopeless  conditions.  But  when  several  of  them  occur  together, 
the  prospect  of  recovery  is  much  diminished,  and  transfusion  would 
then  be  fully  justified,  especially  as  there  is  no  reason  to  think  that 
a  fatal  result  has  ever  been  directly  traced  to  its  employment.  In- 
deed, like  most  other  obstetric  operations,  it  is  more  likely  to  be 
postponed  until  too  late  to  be  of  service,  than  to  be  employed  too 
early;  and  in  some  of  the  cases  reported  as  unsuccessful,  it  was  not 
performed  until  respiration  had  ceased,  and  death  had  actually  taken 
place.  It  has  been  sometimes  said  that  transfusion  can  never  be 
employed  if  the  uterus  be  not  firmly  contracted,  so  as  to  prevent  the 
injected  blood  again  escaping  through  the  uterine  sinuses.  The  cases 
in  which  this  is  likely  to  occur  are  few;  and  if  one  were  met  with, 
the  escape  of  blood  could  be  prevented  by  the  injection  into  the 
uterus  of  the  perchloride  of  iron. 

Description  of  the  Operation. — In  describing  the  operation  I  shall 
limit  myself  to  an  account  of  Aveling's  method  of  immediate  trans- 
fusion, and  to  that  of  injecting  defibrinated  blood.  I  consider  myself 
justified  in  omitting  any  account  of  the  numerous  apparatuses  which 
have  been  invented  for  the  purpose  of  injecting  pure  blood,  since  I 
believe  the  practical  difficulties  are  too  great  ever  to  render  this  form 
of  operation  serviceable.  The  great  objection  to  most  of  the  instru- 
ments used  is  their  cost  and  complexity  :  and  as  long  as  any  special 
apparatus  is  considered  essential,  the  full  benefits  to  be  derived  from 
transfusion  are  not  likely  to  be  realized.  The  necessity  for  ernplov- 
ing  it  arises  suddenly ;  it  may  be  in  a  locality  in  which  it  is  impossi- 
ble to  procure  a  special  instrument;  and  it  would  be  well  if  it  were 
understood  that  transfusion  may  be  safely  and  effectually  performed 
by  the  simplest  means.  In  many  of  the  successful  cases  an  ordinary 
syringe  was  used ;  in  one,  in  the  absence  of  other  instruments,  a 
child's  toy  syringe  was  employed.  I  have  myself  performed  it  with 
a  simple  syringe  purchased  at  the  nearest  chemist's  shop,  when  a 
special  transfusion  apparatus  failed  to  act  satisfactorily. 

Method  of  performing  Immediate  Transfusion. — In  immediate  trans- 
fusion (Fig.  180),  the  donor  is  seated  close  to  the  patient,  and  the 
veins  in  the  arms  of  each  having  been  opened,  the  silver  canula  at 
either  end  of  the  instrument  is  introduced  into  them  (A  B).  The  tube 
between  the  bulb  and  the  patient  is  now  pinched  (D),  so  as  to  form  a 
vacuum,  and  the  bulb  becomes  filled  with  blood  from  the  donor. 
The  finger  is  now  removed  so  as  to  compress  the  distal  tube  (D'), 
and  the  bulb  being  compressed  (c),  its  contents  are  injected  into  the 
patient's  vein.  The  bulb  is  calculated  to  hold  about  two  drachms, 
so  that  the  amount  injected  can  be  estimated  by  the  number  of  times 
it  is  emptied.  The  risk  of  injecting  air  is  prevented  by  filling  the 
syringe  with  water,  which  is  injected  before  the  blood. 

Injection  of  Defibrinated  Blood. — For  injecting  defibrinated  blood 
various  contrivances  have  been  used.  McDonnell's  instrument  is  a 
simple  cylinder  with  a  nozzle  attached,  from  which  the  blood  is  pro- 


THE    TRANSFUSION    OF    BLOOD. 


521 


pelled  by  gravitation.  When  the  propulsive  power  is  insufficient, 
increased  pressure  is  applied  by  breathing  forcibly  into  the  open  end 
of  the  receiver.  l)e  Belina's  instrument  is  on  the  same  principle, 
only  atmospheric  pressure  is  supplied  by  a  contrivance  similar  to 


FIG.  180. 


Method  of  Transfusion  by  Aveling's  Apparatus. 

Eichardson's  spray-producer,  attached  to  one  end.  The  idea  is  simple,. 
but  there  is  some  doubt  of  a  gravitation  instrument  being  sufficiently 
powerful,  and  it  certainly  failed  in  my  hands.  I  have  had  valves 
applied  to  Aveling's  instrument,  so  that  it  works  by  compression  of 
the  bulb,  like  an  ordinary  Higginson's  syringe.  This,  with  a  single 
silver  canula  at  one  end,  for  introduction  into  the  vein,  farms  a  per- 
fect and  inexpensive  transfusion  apparatus,  taking  up  scarcely  any 
space.  If  it  be  not  at  hand,  any  small  syringe,  with  a  tolerably  fine 
nozzle,  may  be  used. 

Mode  of  Preparing  the  Blood. — The  first  step  of  tue  operation  is. 
defibrination  of  the  blood,  which  should,  if  possible,  be  prepared  in, 
an  apartment  adjoining  the  patient's.  The  blood  should  be  taken 
from  the  arm  of  a  strong  and  healthy  man.  The  quality  cannot  be 
unimportant,  and,  in  some  recorded  cases,  the  failure  of  the  operation 
has  been  attributed  to  the  fact  of  the  donor  having  been  a  weakly 
female.  The  supply  from  a  woman  might  also  prove  insufficient ;, 
and,  although  it  has  been  shown  that  blood  from  two  or  more  per- 
sons may  be  used  with  safety,  yet  such  a  change  necessarily  causes, 
delay,  and  should,  if  possible,  be  avoided.  A  vein  having  been 
opened,  eight  or  ten  ounces  of  blood  are  withdrawn,  and  received 
into  some  perfectly  clean  vessel,  such  as  a  dessert  finger-glass.  As  it 
flows  it  should  be  briskly  agitated  with  a  clean  silver  fork,  or  a  glass 
rod,  and,  very  shortly,  strings  of  fibrine  begin  to  form.  It  is  now 
strained  through  a  piece  of  fine  muslin,  previously  dipped  in  hot 
water,  into  a  second  vessel  which  is  floating  in  water  at  a  tempera- 
ture of  about  105°.  By  this  straining  the  fibrine  and  air-bubbles 
resulting  from  the  agitation  are  removed,  and,  if  there  be  no  exces- 
sive hurry,  it  might  be  well  to  repeat  the  straining  a  second  time.  It 
the  vessel  be  kept  floating  in  warm  water,  the  blood  is  prevented 
34 


522  OBSTETRIC  OPERATIONS. 

from  getting  cool,  and  we  can  now  proceed  to  prepare  the  arm  of  the 
patient  for  injection. 

Mode  of  Exposing  the  Veins  selected  for  Transfusion. — This  is  the 
most  delicate  and  difficult  part  of  the  operation,  since  the  veins  are 
generally  collapsed  and  empty,  and  by  no  means  easy  to  find.  The 
best  way  of  exposing  them  is  that  practised  by  McDonnell,  who 
pinches  up  a  fold  of  the  skin  at  the  bend  of  the  elbow,  and  transfixes 
it  with  a  fine  tenotomy  knife  or  scalpel,  so  making  a  gaping  wound 
in  the  integument,  at  the  bottom  of  which  they  are  seen  lying.  A 
probe  should  now  be  passed  underneath  the  vein  selected  for  opening, 
so  as  to  avoid  the  chance  of  its  being  lost  at  any  subsequent  stage  of 
the  operation.  This  is  a  point  of  some  importance,  and  from  the  neglect 
of  this  precaution  I  have  been  obliged  to  open  another  vein  than  that 
originally  fixed  on.  A  small  portion  of  the  vein  being  raised  with 
the  forceps,  a  nick  is  made  into  it  for  the  passage  of  the  canula. 

Injection  of  the  Blood. — The  prepared  blood  is  now  brought  to  the 
bedside,  and,  the  apparatus  having  been  previously  filled  with  blood 
to  avoid  the  risk  of  injecting  any  bubbles  of  air,  the  canula  is  in- 
serted into  the  opening  made  in  the  vein,  and  transfusion  commenced. 
It  should  be  constantly  borne  in  mind  that  this  part  of  the  operation 
should  be  conducted  with  the  greatest  caution,  the  blood  introduced 
very  slowly,  and  the  effect  on  the  patient  carefully  watched.  The 
injection  may  be  proceeded  with  until  some  perceptible  effect  is  pro- 
duced, which  will  generally  be  a  return  of  the  pulsation,  first  at  the 
heart,  and  subsequently  at  the  wrist,  an  increase  in  the  temperature 
of  the  body,  greater  depth  and  frequency  of  the  respirations,  and  a 
general  appearance  of  returning  animation  about  the  countenance. 
Sometimes  the  arms  have  been  thrown  about,  or  spasmodic  twitch  - 
ings  of  the  face  have  taken  place.  The  quantity  of  blood  required 
to  produce  these  effects  varies  greatly,  but  in  the  majority  of  cases 
has  been  very  small.  Occasionally  2  ounces  have  proved  sufficient, 
and  the  average  may  be  taken  as  ranging  between  4  and  6 :  although 
in  a  few  cases  between  10  and  20  have  been  used.  The  practical 
rule  is  to  proceed  very  slowrly  with  the  injection  until  some  per- 
ceptible result  is  observed.  Should  embarrassed  or  frequent  respira- 
tion supervene,  we  may  suspect  that  we  have  been  injecting  either 
too  great  a  quantity  of  blood,  or  with  too  much  force  and  rapidity, 
and  the  operation  should  at  once  be  suspended,  and  not  resumed  until 
the  suspicious  symptoms  have  passed  away.  It  may  happen  that  the 
effects  of  the  transfusion  have  been  highly  satisfactory,  but  that  in 
the  course  of  time  there  is  evidence  of  returning  syncope.  This  may 
possibly  be  prevented  by  the  administration  of  stimulants ;  but  if 
these  fail  there  is  no  reason  why  a  fresh  supply  of  blood  should  not 
again  be  injected,  but  this  should  be  done  before  the  effects  of  the 
first  transfusion  have  entirely  passed  away. 

Secondary  Effects  of  Transfusion. — The  subsequent  effects  in  suc- 
cessful cases  of  transfusion  merit  careful  study.  In  some  few  cases 
death  is  said  to  have  happened  within  a  few  weeks,  with  symptoms 
resembling  pyaemia.  Too  little  is  known  on  this  point,  howTever,  to 
justify  any  positive  conclusions  with  regard  to  it. 

[For  an  account  of  the  intra- venous  injection  of  milk,  see  Appen- 
dix.—ED.] 


PART    V. 

THE  PUERPERAL  STATE 


CHAPTER  I. 
THE    PUERPERAL    STATE   AND   ITS    MANAGEMENT. 

Importance  of  Studying  the  Puerperal  State. — The  key  to  the  man- 
agement of  women  after  labor,  and  to  the  proper  understanding  of 
the  many  important  diseases  which  may  then  occur,  is  to  be  found  in 
a  study  of  the  phenomena  following  delivery,  and  of  the  changes 
going  on  in  the  mother's  system  during  the  puerperal  period.  No 
doubt  natural  labor  is  a  physiological  and  healthy  function,  and 
during  recovery  from  its  effects  disease  should  not  occur.  It  must 
not  be  forgotten,  however,  that  none  of  our  patients  are  under  phy- 
siologically healthy  conditions.  The  surroundings  of  the  lying-in 
woman,  the  effects  of  civilization,  of  errors  of  diet,  of  defective  clean- 
liness, of  exposure  to  contagion,  and  of  a  hundred  other  conditions, 
which  it  is  impossible  to  appreciate,  have  most  important  influences 
on  the  results  of  childbirth.  Hence  it  follows  that  labor,  even  under 
the  most  favorable  conditions,  is  attended  with  considerable  risk. 

The  Mortality  of  Childbirth. — It  is  not  easy  to  say  with  accuracy 
what  is  the  precise  mortality  accompanying  childbirth  in  ordinary 
domestic  practice,  since  the  returns  derived  from  the  reports  of  the 
Registrar-General,  or  from  private  sources,  are  manifestly  open  to 
serious  error.  The  nearest  approach  to  a  reliable  estimate  is  that 
made  by  Dr.  Matthews  Duncan,1  who  calculates  from  figures  derived 
from  various  sources,  that  not  fewer  than  1  out  of  every  120  women, 
delivered  at  or  near  the  full  time,  dies  within  four  weeks  of  child- 
birth. This  indicates  a  mortality  far  above  that  which  has  been 
generally  believed  to  accompany  child-bearing  under  favorable  cir- 
cumstances. It,  however,  closely  approximates  to  a  similar  estimate 
made  by  McClintock,2  who  calculates  the  mortality  in  England  and 
Wales  as  1  in  126 ;  and  in  the  upper  and  middle  classes  alone,  where 
the  conditions  may  naturally  be  supposed  to  be  more  favorable,  as  1 
in  146.  In  these  calculations  there  are  some  obvious  sources  of 
error,  since  they  include  deaths  from  all  causes  within  four  weeks  of 
delivery,  some  of  which  must  have  been  independent  of  the  puerperal 
state. 

1  "The  Mortality  of  Childbed,"  Edin.  Med.  Journ.,  Nov.  1869. 

2  Dublin  Quarterly  Journ.,  Aug.  1869. 


524  THE    PUERPERAL    STATE. 

But  it  is  not  the  deaths  alone  which  should  be  considered.  All 
practitioners  know  how  large  a  number  of  their  patients  suffer  from 
morbid  states  which  may  be  directly  traced  to  the  effects  of  child- 
bearing.  It  is  impossible  to  arrive  at  any  statistical  conclusion  on 
this  point,  but  it  must  have  a  very  sensible  and  important  influence 
on  the  health  of  child-bearing  women. 

Alterations  in  the  Blood  after  Delivery. — The  state  of  the  blood 
during  pregnancy,  already  referred  to,  has  an  important  bearing  on 
the  puerperal  state.  There  is  hyperinosis,  which  is  largely  increased 
by  the  changes  going  on  immediately  after  the  birth  of  the  child  ;  for 
then  the  large  supply  of  blood,  which  has  been  going  to  the  uterus, 
is  suddenly  stopped,  and  the  system  must  also  get  rid  of  a  quantity 
of  effete  matter  thrown  into  the  circulation,  in  consequence  of  the 
degenerative  changes  occurring  in  the  muscular  fibres  of  the  uterus. 
Hence  all  the  depurative  channels,  by  which  this  can  be  eliminated,  are 
called  on  to  act  with  great  activity.  If,  in  addition,  the  peculiar  con- 
dition of  the  generative  tract  be  borne  in  mind — viz.,  the  large  open 
vessels  on  its  inner  surface — the  partially  bared  inner  surface  of  the 
uterus,  and  'the  channels  for  absorption  existing  in  consequence  of 
slight  lacerations  in  the  cervix  or  vagina — it  is  not  a  matter  of  sur- 
prise that  septic  diseases  should  be  so  common. 

Condition  after  Delivery. — It  will  be  well  to  consider  successively 
the  various  changes  going  on  after  delivery,  and  then  we  shall  be 
in  a  better  position  for  studying  the  rational  management  of  the 
puerperal  state. 

Nervous  Shock. — Some  degree  of  nervous  shock  or  exhaustion  is 
observable  after  most  labors.  In  many  cases  it  is  entirely  absent ; 
in  others  it  is  well  marked.  Its  amount  is  in  proportion  to  the 
severity  of  the  labor,  and  the  susceptibility  of  the  patient ;  and  it  is, 
therefore,  most  likely  to  be  excessive  in  women  who  have  suffered 
greatly  from  pain,  who  have  undergone  much  muscular  exertion,  or 
who  have  been  weakened  from  undue  loss  of  blood.  It  is  evidenced 
by  a  feeling  of  exhaustion  and  fatigue,  and  not  uncommonly  there 
is  some  shivering,  which  soon  passes  off,  and  is  generally  followed 
by  refreshing  sleep.  The  extreme  nervous  susceptibility  continues 
for  a  considerable  time  after  delivery,  and  indicates  the  necessity  of 
keeping  the' lying-in  patient  as  free  from  all  sources  of  excitement  as 
possible. 

Fall  of  the  Pulse. — Immediately  after  delivery  the  pulse  falls,  and 
the  importance  of  this,  as  indicating  a  favorable  state  of  the  patient, 
has  already  been  alluded  to.  The  condition  of  the  pulse  has  been 
carefully  studied  by  Blot,1  who  has  shown  that  this  diminution, 
which  he  believes  to  be  connected  with  an  increased  tension  in  the 
arteries,  due  to  the  sudden  arrest  of  the  uterine  circulation,  continues, 
in  a  large  proportion  of  cases,  for  a  considerable  number  of  days 
after  Delivery  ;  and,  as  a  matter  of  clinical  import,  as  long  as  it  does, 
the  patient  may  be  considered  to  be  in  a  favorable  state.  In  many 
instances  the  slowness  of  the  pulse  is  remarkable,  often  sinking  to 

1  Arch.  G6n.  de  M6cl.,  1864. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  o2o 

50  or  even  40  beats  per  minute.  Any  increase  above  the  normal 
rate,  especially  if  at  all  continuous,  should  always  be  carefully  noted, 
and  looked  on  with  suspicion.  In  connection  with  this  subject, 
however,  it  must  be  remembered  that  in  puerperal  women  the  most 
trivial  circumstances  may  cause  a  sudden  rise  of  the  pulse.  This 
must  be  familiar  to  every  practical  obstetrician,  who  has  constant 
opportunities  of  observing  this  effect  after  any  transient  excitement 
or  fatigue.  In  lying-in  hospitals  it  has  generally  been  observed  that 
the  occurrence  of  any  particularly  bad  case  will  send  up  the  pulse  of 
all  the  other  patients  who  may  have  heard  of  it. 

Temperature  in  the  Puerperal  State. — The  temperature  in  the  lying- 
in  state  affords  much  valuable  information.  Daring,  and  for  a  short 
time  after  labor,  there  is  a  slight  elevation.  It.  soon  falls  to,  or  even 
somewhat  below,  the  normal  level.  Squire  found  that  the  fall  oc- 
curred within  twenty-four  hours,  sometimes  within  twelve  hours, 
after  the  termination  of  labor.1  For  a  few  days  there  is  often  a 
slight  increase  of  temperature,  which  is  probably  caused  by  the  rapid 
oxidation  of  tissue  in  connection  with  the  involution  of  the  uterus. 
In  about  forty-eight  hours  there  is  a  rise  connected  with  the  estab- 
lishment of  lactation,  amounting  to  one  or  two  degrees  over  the 
normal  level;  but  this  again  subsides  as  soon  as  the  milk  is  freely 
secreted.  Crode"  has  also  shown*  that  rapid,  but  transient,  rises  of 
temperature  may  occur  at  any  period,  connected  with  trivial  causes, 
such  as  constipation,  errors  of  diet,  or  mental  disturbances.  But,  if 
there  be  any  rise  of  temperature  which  is  at  all  continuous,  especially 
to  over  100°  Fahr.,  and  associated  with  rapidity  of  the  pulse,  there 
is  reason  to  fear  the  existence  of  some  complication. 

The  /Secretions  and  Excretions. — The  various  secretions  and  excre- 
tions are  carried  on  with  increased  activity  after  labor.  The  skin 
especially  acts  freely,  the  patient  often  sweating  profusely.  There 
is  also  an  abundant  secretion  of  urine,  but  not  uncommonly  a  diffi- 
culty of  voiding  it,  either  on  account  of  temporary  paralysis  of  the 
neck  of  the  bladder,  resulting  from  the  pressure  to  which  it  has  been 
subjected,  or  from  swelling  and  occlusion  of  the  urethra.  For  the 
same  reason  the  rectum  is  eluggish  for  a  time,  and  constipation  is 
not  infrequent.  The  appetite  is  generally  indifferent,  and  the  patient 
is  often  thirsty. 

Secretion  of  Milk. — Generally  in  about  forty-eight  hours  the  secre- 
tion of  milk  becomes  established,  and  this  is  occasionally  accompanied 
by  a  certain  amount  of  constitutional  irritation.  The  breasts  often 
become  turgid,  hot,  and  painful.  There  may,  or  may  not,  be  some 
general  disturbance,  quickening  of  pulse,  elevation  of  temperature, 
possibly  slight  shivering,  and  a  general  sense  of  oppression,  which 
are  quickly  relieved  as  the  milk  is  formed,  and  the  breasts  emptied 
by  suckling.  Squire  says  that  the  most  constant  phenomenon  con- 
nected with  the  temperature  is  a  slight  elevation  as  the  milk  is 
secreted,  rapidly  falling  when  lactation  is  established.  Barker  noted 

1  "Puerperal  Temperatures,"  Obstetrical  Transactions,  vol.  ix. 

2  Monat.  f.  Geburt,  Dec.  1868. 


526  THE    PUERPERAL    STATE. 

elevation,  cither  of  temperature  or  pulse,  in  only  4  out  of  52  cases 
which  were  carefully  watched.  There  can  be  little  doubt  that  the 
importance  of  the  so-called  "milk  fever"  has  been  immensely  ex- 
aggerated, and  its  existence,  as  a  normal  accompaniment  of  the 
puerperal  state,  is  more  than  doubtful.  It  is  certain,  however,  that, 
in  a  small  minority  of  cases,  there  is  an  appreciable  amount  of  dis- 
turbance about  the  time  that  the  milk  is  formed.  Many  modern 
writers,  such  as  Winckel,  Grunewaldt,  and  d'Espine,  entirely  deny 
the  connection  of  this  disturbance  with  lactation,  and  refer  it  to  a 
slight  and  transient  septicaemia.  Graily  Hewitt  remarks  that  it  is 
most  commonly  met  with  when  the  patient  is  kept  low  and  on  defi- 
cient diet  after  delivery,  especially  when  the  system  is  below  par 
from  hemorrhage,  or  any  other  cause.  This  observation  will,  no 
doubt,  account  for  the  comparative  rarity  of  febrile  disturbance  in 
connection  with  lactation  in  these  days,  in  which  the  starving  of 
puerperal  patients  is  not  considered  necessary.  It  is  certain  that 
anything  deserving  the  name  of  milk  fever  is  now  altogether  excep- 
tional, and  such  feverishness  as  exists  is  generally  quite  transient. 
It  is  also  a  fact,  that  it  is  most  apt  to  occur  in  delicate  and  weakly 
women,  especially  in  those  who  do  not,  or  are  unable  to,  nurse. 
There  does  not,  however,  seem  to  be  any  sufficient  reason  for  refer- 
ring it,  even  when  tolerably  well  marked,  to  septicaemia.  The  relief 
which  attends  the  emptying  of  the  breasts  seems  sufficient  to  prove 
its  connection  with  lactation,  and  the  discomfort  which  is  necessarily 
associated  with  the  swollen  and  turgid  mammse,  is,  of  itself,  quite 
sufficient  to  explain  it. 

Contraction  of  the  Uterus  after  Delivery. — Immediately  after  de- 
livery the  uterus  contracts  firmly,  and  can  be  felt  at  the  lower  part 
of  the  abdomen  as  a  hard,  firm  mass,  about  the  size  of  a  cricket  Ball. 
After  a  time  it  again  relaxes  somewhat,  and  alternate  relaxations  and 
contractions  go  on,  at  intervals,  for  a  considerable  time  after  the 
expulsion  of  the  placenta.  The  more  complete  and  permanent  the 
contraction,  the  greater  the  safety  and  comfort  of  the  patient ;  for 
when  the  organ  remains  in  a  state  of  partial  relaxation,  coagula  are 
apt  to  be  retained  in  its  cavity,  while,  for  the  same  reason,  air  enters 
more  readily  into  it.  Hence  decomposition  is  favored,  and  the  chances 
of  septic  absorption  are  much  increased ;  while,  even  when  this  does 
not  occur,  the  muscular  fibres  are  excited  to  contract,  and  severe 
after-pains  are  produced. 

Subsequent  Diminution  in  the  Size  of  the  Uterus. — After  the  first 
few  days  the  diminution  in  the  size  of  the  uterus  progresses  with 
great  rapidity.  By  about  the  sixth  day  it  is  so  much  lessened  as  to 
project  not  more  than  1 J  or  2  inches  above  the  pelvic  brim,  while  by 
the  eleventh  day  it  is  no  longer  to  be  made  out  by  abdominal  palpa- 
tion. Its  increased  size  is,  however,  still  apparent  per  vaginam,  and, 
should  occasion  arise  for  making  an  internal  examination,  the  mass 
of  the  lower  segment  of  the  uterus,  with  its  flabby  and  patulous 
cervix,  can  be  felt  for  some  weeks  after  delivery.  This  may  some- 
times be  of  practical  value  in  cases  in  which  it  is  necessary  to  ascer- 
tain the  fact  of  recent  delivery,  and,  under  these  circumstances,  as 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT.  527 

pointed  out  by  Simpson,  the  uterine  sound  would  also  enable  us  to 
prove  that  the  cavity  of  the  uterus  is  considerably  elongated.  Indeed 
the  normal  condition  of  the  uterus  and  cervix  is  not  regained  until 
six  weeks  or  two  months  after  labor.  These  observations  are  corro- 
borated by  investigations  on  the  weight  of  the  organ  at  different 
periods  after  labor.  Thus  Heschl1  has  shown  that  the  uterus,  imme- 
diately after  delivery,  weighs  about  22  to  24  ozs. ;  within  a  week,  it 
weighs  19  to  21  ozs.;  and  at  the  end  of  the  second  week,  10  to  11 
ozs.  only.  At  the  end  of  the  third  week,  it  weighs  5  to  7  ozs.;  but 
it  is  not  until  the  end  of  the  second  month  that  it  reaches  its  normal 
weight.  Hence  it  appears  that  the  most  rapid  diminution  occurs 
during  the  second  week  after  delivery. 

Fatty  Transformation  of  the  Muscular  Fibres. — The  mode  in  which 
this  diminution  in  size  is  effected  is  by  the  transformation  of  the 
muscular  fibres  into  molecular  fat,  which  is  absorbed  into  the  mater- 
nal vascular  system,  which,  therefore,  becomes  loaded  with  a  large 
amount  of  effete  material.  Heschl  has  shown  that  the  entire  mass 
of  the  enlarged  uterine  muscles  are  removed,  and  replaced  by  newly  - 
formed  fibres,  which  commence  to  be  developed  about  the  fourth 
week  after  delivery,  the  change  being  complete  about  the  end  of  the 
second  month.  Generally  speaking,  involution  goes  on  without  inter- 
ruption. It  is,  however,  apt  to  be  interfered  with  by  a  variety  of 
causes,  such  as  premature  exertion,  intercurrent  disease,  and,  very 
probably,  by  neglect  of  lactation.  Hence  the  uterus  often  remains 
large  and  bulky,  and  the  foundation  for  many  subsequent  uterine 
ailments  is  laid. 

Changes  in  the  Uterine  Vessels. — Williams  has  drawn  attention  to 
changes  occurring  in  the  vessels  of  the  uterus,  some  of  which  seem 
to  be  permanent,  and  may,  should  further  observations  corroborate 
his  investigations,  prove  of  value  in  enabling  us  to  ascertain  whether 
a  uterus  is  nulliparous  or  the  reverse ;  a  question  which  may  be  of 
medico-legal  importance.  After  pregnancy  he  found  all  the  vessels 
enlarged  in  calibre.  The  coats  of  the  arteries  are  thickened  and 
hypertrophied,  and  this  he  has  observed  even  in  the  uteri  of  aged 
women  who  have  not  borce  children  for  may  years.  The  venous 
sinuses,  especially  at  the  placental  site,  have  their  walls  greatly 
thickened  and  convoluted,  and  contain  in  their  centre  a  small  clot  of 
blood  (Fig.  181).  This  thickening  attains  its  greatest  dimensions  in 
the  third  month  after  gestation,  but  traces  of  it  may  be  detected  as 
late  as  ten  or  twelve  weeks  after  labor. 

Changes  in  the  Uterine  Mucous  Membrane. — The  changes  going  on 
in  the  lining  membrane  of  the  uterus  immediately  after  delivery  are 
of  great  importance  in  leading  to  a  knowledge  of  the  puerperal  state, 
and  have  already  been  discussed  when  describing  the  decidua  (p.  94). 
Its  cavity  is  covered  with  a  reddish-gray  film,  formed  of  blood  and 
fibrine.  The  open  mouths  of  the  uterine  sinuses  are  still  visible, 
more  especially  over  the  site  of  the  placenta,  and  thrombi  may  be 

1  Researches  on  the  Conduct  of  the  Human  Uterus  after  Delivery. 


528 


THE    PUERPERAL    STATE. 


seen  projecting  from  them.  The  plaeental  site  can  be  distinctly  made 
out,  in  the  form  of  an  irregularly  oval  patch,  where  the  lining  mem- 
brane is  thicker  than  elsewhere. 

Fio.  isi. 


Section  of  a  Uterine  Sinus  from  the  Placental  Site  nine  weeks  after  Delivery.     (After  Williams.) 

Contraction  of  the  Vayina,  etc. — The  vagina  soon  contracts,  and,  by 
the  time  the  puerperal  month  is  over,  it  has  returned  to  its  normal 
dimensions,  but  after  child-bearing  it  always  remains  more  lax,  and 
less  rugous,  than  in  nulliparse.  The  vulva,  at  first  very  lax  and 
much  distended,  soon  regains  its  former  state.  The  abdominal  pari- 
etes  remain  loose  and  flabby  for  a  considerable  time,  and  the  white 
streaks,  produced  by  the  distension  of  the  cutis,  very  generally  be- 
come permanent.  In  some  women,  especially  when  proper  support 
by  bandaging  has  not  been  given,  the  abdomen  remains  permanently 
loose  and  pendulous. 

The  Lochial  Discharge. — From  the  time  of  delivery,  up  to  about 
three  weeks  afterwards,  a  discharge  escapes  from  the  interior  of  the 
uterus,  known  as  the  lochia.  At  first  this  consists  almost  entirely  of 
pure  blood,  mixed  with  a  variable  amount  of  coagula.  If  efficient 
uterine  contraction  have  not  been  secured  after  the  expulsion  of  the 
placenta,  coagula  of  considerable  size  are  frequently  expelled  with 
the  lochia  for  one  or  two  days  after  delivery.  In  three  or  four  days 
the  distinctly  bloody  character  of  the  lochia  is  altered.  They  have 
a  reddish  watery  appearance,  and  are  known  as  the  lochia  rubra  or 
cruenta.  According  to  the  researches  of  Wertheimer,1  they  are  at 

1  Virchow's  Arch.,  1861. 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT. 

this  time  composed  chiefly  of  blood  corpuscles,  mixed  with  epithelium 
scales,  mucous  corpuscles,  and  the  debris  of  the  decidua.  The  change 
in  the  appearance  of  the  discharge  progresses  gradually,  and  about 
the  seventh  or  eighth  day  it  has  no  longer  a  red  color,  but  is  a  pale 
greenish  fluid,  with  a  peculiar  sickening  and  disagreeable  odor,  and 
is  familiarly  described  as  the  "green  waters."  It  now  contains  a 
smaller  quantity  of  blood  corpuscles,  which  lessen  in  amount  from 
day  today,  but  a  considerable  number  of  pus  corpuscles,  which  re- 
main the  principal  constituent  of  the  discharge  until  it  ceases.  Besides 
these,  epithelial  scales,  fatty  granules,  and  crystals  of  cholesterine, 
are  observed.  Occasionally  a  small  infusorium,  which  has  been 
named  the  "trichomena  vaginalis,"  has  been  detected;  but  it  is  into 
of  constant  occurrence. 

Variation  in  its  Amount  and  Duration. — The  amount  of  the  lochia 
varies  much,  and  in  some  women  it  is  habitually  more  abundant 
than  in  others.  Under  ordinary  circumstances  it  is  very  scanty  after 
the  first  fortnight,  but  occasionally  it  continues  somewhat  abundant 
for  a  month  or  more,  without  any  bad  results.  It  is  apt  again  to 
become  of  a  red  color,  and  to  increase  in  quantity,  in  consequence 
of  any  slight  excitement  or  disturbance.  If  this  red  discharge  con- 
tinue for  any  undue  length  of  time,  there  is  reason  to  suspect  some 
abnormality,  and  it  may  not  unfrequently  be  traced  to  slight  lacera- 
tions about  the  cervix,  which  have  not  healed  properly.  This  result 
may  also  follow  premature  exertion,  interfering  with  the  proper  in- 
volution of  the  uterus;  and  the  patient  should  certainly  not  be 
allowed  to  move  about  as  long  as  much  colored  discharge  is  going  on. 

Occasional  Fetor  of  the  Discharge. — Occasionally  the  lochia  have 
an  intensely  fetid  odor.  This  must  always  give  rise  to  some  anxiety, 
since  it  often  indicates  the  retention  and  putrefaction  of  coagula,  and 
involves  the  risk  of  septic  absorption.  It  is  not  very  rare,  however, 
to  observe  a  most  disagreeable  odor  persist  in  the  lochia  without  any 
bad  results.  The  fetor  always  deserves  careful  attention,  and  an 
endeavor  should  be  made  to  obviate  it  by  directing  the  nurse  to 
syringe  out  the  vagina  freely  night  and  morning  with  Condy's  fluid 
and  water;  while,  if  it  be  associated  with  quickened  pulse  and 
elevated  temperature,  other  measures,  to  be  subsequently  described, 
will  be  necessary. 

The  after-pains,  which  many  child-bearing  women  dread  even 
more  than  the  labor-pains,  are  irregular  contractions,  occurring  for 
a  varying  time  after  delivery,  and  resulting  from  the  efforts  of  the 
uterus  to  expel  coagula  which  have  formed  in  its  interior.  If,  there- 
fore, special  care  be  taken  to  secure  complete  and  permanent  con- 
traction after  labor,  they  rarely  occur,  or  to  a  very  slight  extent. 
Their  dependence  on  uterine  inertia  is  evidenced  by  the  common 
observation  that  they  are  seldom  met  with  in  primiparse,  in  whom 
uterine  contraction  may  be  supposed  to  be  more  efficient,  and  are 
most  frequent  in  women  who  have  borne  many  children.  They  are 
a  preventible  complication,  and  one  which  need  not  give  rise  to  any 
anxiety;  they  are,  indeed,  rather  salutary  than  the  reverse,  for  if 
coagula  be  retained  in  utero,  the  sooner  they  are  expelled  the  better. 


530  THE    PUERPERAL    STATE. 

The  after-pains  generally  begin  a  few  hours  after  delivery,  and  con- 
tinue in  bad  cases,  for  three  or  four  days,  but  seldom  longer.  [These 
pains  are  frequently  increased  immediately  upon  giving  the  child 
the  breast,  the  drawing  of  the  milk  acting  sympathetically  upon  the 
uterus  and  causing  much  annoyance. — ED.]  When  at  their  height 
they  are  often  relieved  by  the  expulsion  of  the  coagula.  They  may 
be  readily  distinguished  from  pains  due  to  more  serious  causes,  by 
feeling  the  enlarged  uterus  harden  under  their  influence,  by  the 
uterus  not  being  tender  on  pressure,  and  by  the  absence  of  any  con- 
stitutional symptoms. 

Management  of  Women  after  Delivery. — The  management  of  women 
after  child-birth  has  varied  much  at  different  times,  according  to 
fashion  or  theory.  The  dread  of  inflammation  long  influenced  the 
professional  mind,  and  caused  the  adoption  of  a  strictly  antiphlo- 
gistic diet,  which  led  to  a  tardy  convalescence.  The  recognition  of 
the  essentially  physiological  character  of  labor  has  resulted  in  more 
sound  views,  with  manifest  advantage  to  our  patients.  The  main 
facts  to  bear  in  mind  with  regard  to  the  puerperal  woman  are,  her 
nervous  susceptibility,  which  necessitates  quiet  and  absence  of  all 
excitement;  the  importance  of  favoring  involution  by  prolonged 
rest ;  and  the  risk  of  septicaemia,  which  calls  for  perfect  cleanliness 
and  attention  to  hygienic  precautions. 

The  Administration  of  Opiates  is  generally  Unadvisable. — As  soon 
as  we  are  satisfied  that  the  uterus  is  perfectly  contracted,  and  that 
all  risk  of  hemorrhage  is  over,  the  patient  should  be  left  to  sleep. 
Many  practitioners  administer  an  opiate;  but,  as  a  matter  of  routine, 
this  is  certainly  not  good  practice,  since  it  checks  the  contractions  of 
the  uterus,  and  often  produces  unpleasant  effects.  Still,  if  the  labor 
have  been  long  and  tedious,  and  the  patient  be  much  exhausted,  15 
or  20  drops  of  Battley's  solution  may  be  administered  with  advantage. 

Attention  to  the  State  of  the  Pulse,  Bladder,  and  Uterus. — Within  a 
few  hours  the  patient  should  be  seen,  and  at  the  first  visit  particular 
attention  should  be  paid  to  the  state  of  the  pulse,  the  uterus,  and 
the  bladder.  The  pulse  during  the  whole  period  of  convalescence 
should  be  carefully  watched,  and,  if  it  be  at  all  elevated,  the  tem- 
perature should  at  once  be  taken.  If  the  pulse  and  temperature 
remain  normal,  we  may  be  satisfied  that  things  are  going  on  well ; 
but  if  the  one  be  quickened  and  the  other  elevated,  some  disturbance 
or  complication  may  be  apprehended.  The  abdomen  should  be  felt 
to  see  that  the  uterus  is  not  unduly  distended,  and  that  there  is  no 
tenderness.  After  the  first  day  or  two  this  is  no  longer  necessary. 

Treatment  of  Retention  of  Urine. — Sometimes  the  patient  cannot 
at  first  void  the  urine,  and  the  application  of  a  hot  sponge  over  the 
pubis  may  enable  her  to  do  so.  If  the  retention  of  urine  be  due  to 
temporary  paralysis  of  the  bladder,  three  or  four  20-minim  doses  of 
the  liquid  extract  of  ergot,  at  intervals  of  half  an  hour,  may  prove 
successful.  Many  hours  should  not  be  allowed  to  elapse  without  re- 
lieving the  patient  by  the  catheter,  since  prolonged  retention  is  only 
likely  to  make  matters  worse.  Subsequently,  it  may  be  necessary 
to  empty  the  bladder  night  and  morning,  until  the  patient  regain  her 


THE    PUERPERAL    STATE    AND    ITS    MANAGEMENT. 

power  over  it,  or  until  the  swelling  of  the  urethra  subsides,  and  this 
will  generally  be  the  case  in  a  few  days.  Occasionally  the  bladder 
becomes  largely  distended,  and  is  relieved  to  some  degree  by  drib- 
bling of  urine  from  the  urethra.  Such  a  state  of  things  may  deceive 
the  patient  and  nurse,  and  may  produce  serious  consequences  by 
causing  cystitis.  Attention  to  the  condition  of  the  abdomen  will 
prevent  the  practitioner  from  being  deceived,  for  in  addition  to  some 
constitutional  disturbance,  a  large,  tender,  and  fluctuating  swelling 
will  be  found  in  the  hypogastric  region,  distinct  from  the  uterus, 
which  it  displaces  to  one  or  other  side.  The  catheter  will  at  once 
prove  that  this  is  produced  by  distension  of  the  bladder. 

Treatment  of  Severe  After-pains. — If  the  after-pains  be  very  severe, 
an  opiate  may  be  administered,  or,  if  the  lochia  be  not  over-abund- 
ant, a  linseed-meal  poultice,  sprinkled  with  laudanum,  or  with  the 
chloroform  and  belladonna  liniment,  may  be  applied.  If  proper  care 
have  been  taken  to  induce  uterine  contraction,  they  will  seldom  be 
sufficiently  severe  to  require  treatment.  In  America,  quinine  in 
doses  of  10  grains  twice  daily,  has  been  strongly  recommended,  espe- 
cially when  opiates  fail,  and  when  the  pains  are  neuralgic  in  character, 
and  I  have  found  this  remedy  answer  extremely  well. 

Diet  and  Regimen. — The  diet  of  the  puerperal  patient  claims  care- 
ful attention,  the  more  so  as  old  prejudices  in  this  respect  are  as  yet 
far  from  exploded,  and  as  it  is  by  no  means  rare  to  find  mothers  and 
nurses  who  still  cling  tenaciously  to  the  idea  that  it  is  essential  to 
prescribe  a  low  regimen  for  many  days  after  labor.  •  The  erroneous- 
ness  of  this  plan  is  now  so  thoroughly  recognized,  that  it  is  hardly 
necessary  to  argue  the  point.  There  is,  however,  a  tendency  in  some 
to  err  in  the  opposite  direction,  which  leads  them  to  insist  on  the 
patient's  consuming  solid  food  too  soon  after  delivery,  before  she  has 
regained  her  appetite,  thereby  producing  nausea  and  intestinal  de- 
rangement. Our  best  guide  in  this  matter  is  the  feelings  of  the  pa- 
tient herself.  If,  as  is  often  the  case,  she  be  disinclined  to  eat,  there 
is  no  reason  why  she  should  be  urged  to  do  so.  A  good  cup  of  beef- 
tea,  some  bread  and  milk,  or  an  egg  beat  up  with  milk,  may  gener- 
ally be  given  with  advantage  shortly  after  delivery,  and  many  patients 
are  not  inclined  to  take  more  for  the  first  day  or  so.  If  the  patient 
be  hungry  there  is  no  reason  why  she  should  not  have  some  more 
solid,  but  easily  digested  food,  such  as  white  fish,  chicken,  or  sweet- 
bread; and,  after  a  day  or  two,  she  may  resume  her  ordinary  diet, 
bearing  in  mind  that,  being  confined  to  bed,  she  cannot  with  advan- 
tage consume  the  same  amount  of  solid  food  as  when  she  is  up  and 
about.  Dr.  Oldham,  in  his  presidential  address  to  the  Obstetrical 
Society,1  has  some  apposite  remarks  on  this  point,  which  are  worthy 
of  quotation.  "A  puerperal  month  under  the  guidance  of  a  monthly 
nurse  is  easily  drawn  out,  and  it  is  well  if  a  love  of  the  comforts  of 
illness  and  the  persuasion  of  being  delicate,  which  are  the  infirmities 
of  many  women,  do  not  induce  a  feeble  life,  which  long  survives 
after  the  occasion  of  it  is  forgotten.  I  know  no  reason  why,  if  a 

1  Obstct.  Trans,  vol.  vi. 


532  THE    PUERPERAL    STATE. 

woman  is  confined  early  in  the  morning,  she  should  not  have  her 
breakfast  of  tea  and  toast  at  nine,  her  luncheon  of  some  digestible 
meat  at  one,  her  cup  of  tea  at  five,  her  dinner  with  chicken  at  seven, 
and  her  tea  again  at  nine,  or  the  equivalent,  according  to  the  varia- 
tion of  her  habits  of  living.  [With  our  ideas  in  the  United  States, 
we  do  not  think  American  women  would  stand  this  sort  of  substan- 
tial diet  so  soon  after  delivery.  In  fact  few  in  the  higher  walks  of 
life  would  care  to  try  the  experiment,  or  have  the  appetite  to  enjoy 
it — ED.]  Of  course,  there  is  the  common  sense  selection  of  articles 
of  food,  guarding  against  excess,  and  avoiding  stimulants.  But  gruel 
and  slops,  and  all  intermediate  feeding,  are  to  be  avoided."  No  one 
who  has  seen  both  methods  adopted  can  fail  to  have  been  struck 
with  the  more  rapid  and  satisfactory  convalescence  which  takes  place 
when  the  patient's  strength  is  not  weakened  by  an  unnecessarily  low 
diet.  Stimulants,  as  a  rule,  are  not  required ;  but,  if  the  patient, 
be  weakly  and  exhausted,  or  if  she  be  accustomed  to  their  use, 
there  can  be  no  reasonable  objection  to  their  judicious  administra- 
tion. 

Attention  to  Cleanliness,  &c. — Immediately  after  delivery  a  warm 
napkin  is  applied  to  the  vulva,  and,  after  the  patient  has  rested  a 
little,  the  nurse  removes  the  soiled  linen  from  the  bed,  and  \vusln.-s 
the  external  genitals.  It  is  impossible  to  pay  too  much  attention 
during  the  subsequent  progress  of  the  case  to  the  maintenance  of 
perfect  cleanliness.  The  linen  should  be  frequently  changed,  and  all 
dirty  linen  and  discharges  immediately  removed  from  the  apartment. 
The  vulva  should  be  washed  daily  with  Condy's  fluid  and  water,  and 
the  patient  will  derive  great  comfort  from  having  the  vagina 
syringed  gently  out  once  a  day  with  the  same  solution.  The  re- 
markable diminution  of  mortality  which  has  followed  such  antisep- 
tic precautions  in  certain  Lying-in  Hospitals  in  Germany,  well  shows 
the  importance  of  these  measures.  The  room  should  be  kept  toler- 
ably cool,  and  fresh  air  freely  admitted. 

Action  of  the  Boivels. — It  is  customary,  on  the  morning  of  the 
second  or  third  clay,  to  secure  an  action  of  the  bowels;  and  there  is 
no  better  way  of  doing  this  than  by  a  large  enema  of  soap  and  water. 
If  the  patient  object  to  this,  and  the  bowels  have  not  acted,  some  mild 
aperient  may  be  administered,  such  as  a  small  dose  of  castor  oil,  a 
few  grains  of  colocynth  and  henbane  pill,  or  the  popular  French 
aperient,  the  "Tamar  Indien." 

Lactation. — -The  management  of  suckling  and  of  the  breasts  forms 
an  important  part  of  the  duties  of  the  monthly  nurse,  which  the  prac- 
titioner should  himself  superintend.  This  will  be  more  conveniently 
discussed  under  the  head  of  lactation. 

Importance  of  Prolonged  Rest. — The  most  important  part  of  the 
management  of  the  puerperal  state  is  the  securing  to  the  patient  pro- 
longed rest  in  the  horizontal  position,  in  order  to  favor  proper  invo- 
lution of  the  uterus.  For  the  first  few  days  she  should  be  kept  as 
quiet  and  still  as  possible,  not  receiving  the  visits  of  any  but  her 
nearest  relatives,  thus  avoiding  all  chance  of  undue  excitement.  It 
is  customary  among  the  better  classes  for  the  patient  to  remain  in 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  533 

bed  for  eight  or  ten  days;  but,  provided  she  be  doing  well,  there  can 
be  no  objection  to  her  lying  on  the  outside  of  the  bed,  or  slipping  on 
to  a  sofa,  somewhat  sooner.  After  ten  days  or  a  fortnight  she  may 
be  permitted  to  sit  on  a  ehair  for  a  little;  but  I  am  convinced  that 
the  longer  she  can  be  persuaded  to  retain  the  recumbent  position, 
the  more  complete  and  satisfactory  will  be  the  progress  of  involution, 
and  she  should  not  be  allowed  to  walk  about  until  the  third  week, 
about  which  time  she  may  also  be  permitted  to  take  a  drive.1  If  it 
be  borne  in  mind  that  it  takes  from  six  weeks  to  two  months  for  the 
uterus  to  regain  its  natural  size,  the  reason  for  prolonged  rest  will  be 
obvious.  The  judicious  practitioner,  however,  while  insisting  on  this 
point,  will  take  measures,  at  the  same  time,  not  to  allow  the  patient 
to  lapse  into  the  habits  of  an  invalid,  or  to  give  the  necessary  rest 
the  semblance  of  disease. 

Subsequent  Treatment.— Towards  the  termination  of  the  puerperal 
month  some  slight  tonic,  such  as  small  doses  of  quinine  with  phos- 
phoric acid,  may  be  often  given  with  advantage,  especially  if  conva- 
lescence be  tardy.  Nothing  is  so  beneficial  in  restoring  the  patient 
to  her  usual  health  as  change  of  air,  and  in  the  upper  classes  a  short 
visit  to  the  seaside  may  generally  be  recommended,  with  the  certainty 
of  much  benefit. 


CHAPTER  II. 

MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration. — Almost  immediately  after  its  ex- 
pulsion, a  healthy  child  cries  aloud,  thereby  showing  that  respiration 
is  established,  and  this  may  be  taken  as  a  signal  of  its  safety.  The 
first  respiratory  movements  are  excited,  partly  by  reflex  action  result- 
ing from  the  contact  of  the  cold  external  air  on  the  cutaneous  nerves, 
and  partly  by  the  direct  irritation  of  the  medulla  oblongata,  in  conse- 
quence of  the  circulation  through  it  of  blood  no  longer  oxygenated 
in  the  placenta. 

Apparent  Death  of  the  New-born  Child. — Not  infrequently  the  child 
is  born  in  ah  apparently  lifeless  state.  This  is  especially  likely  to 
be  the  case  when  the  second  stage  of  labor  has  been  unduly  pro- 
longed, so  that  the  head  has  been  subjected  to  long-continued  pres- 
sure. The  utero-placental  circulation  is  also  apt  to  be  injuriously 
interfered  with  before  the  birth  of  the  child  when  a  tardy  labor  has 

['  In  Paris,  among  patients  of  the  higher  walks  of  life,  the  time  for  remaining  in 
bed  is  usually  twenty-one  days,  even  after  very  easy  labors  :  the  accoucheurs  claiming 
that  this  length  of  rest  is  required,  if  we  expect  to  avoid  uterine  displacements. — ED.] 


534  THE    PUERPERAL    STATE. 

produced  tonic  contraction  of  the  uterus,  and  consequent  closure  of 
the  uterine  sinuses;  or,  more  rarely,  from  such  causes  as  the  injudi- 
cious administration  of  ergot,  premature  separation  of  the  placenta, 
or  compression  of  the  umbilical  cord.  In  any  of  these  cases  it  is 
probable  that  the  arrest  of  the  utero-placental  circulation  induces 
attempts  at  inspiration,  which  are  necessarily  fruitless,  since  air 
cannot  reach  the  lungs,  and  the  foetus  may  die  asphyxiated;  the 
existence  of  the  respiratory  movement  being  proved  on  post-mortem 
examination  by  the  presence  in  the  lungs  of  liquor  amnii,  mucus, 
and  meconium,  and  by  the  extravasation  of  blood  from  the  rupture 
of  their  engorged  vessels. 

Appearance  of  the  Child  in  such  Cases. — In  most  cases,  when  the 
child  is  born  in  a  state  of  apparent  asphyxia,  its  face  is  swollen  and 
of  a  dark  livid  color.  It  not  infrequently  makes  one  or  two  feeble 
and  gasping  efforts  at  respiration,  without  any  definite  cry;  on  aus- 
cultation the  heart  may  be  heard  to  beat  weakly  and  slowly.  Under 
such  circumstances  there  is  a  fair  hope  of  its  recovery.  In  other 
cases  the  child,  instead  of  being  turgid  and  livid  in  the  face,  is  pale, 
with  flaccid  limbs,  and  no  appreciable  cardiac  action,  then  the  prog- 
nosis is  much  more  unfavorable. 

Treatment  of  Apparent  Death. — No  time  should  be  lost  in  endeavor- 
ing to  excite  respiration,  and,  at  first,  this  must  be  done  by  applying 
suitable  stimulants  to  th°  cutaneous  nerves,  in  the  hope  of  exciting 
reflex  action.  The  cord  should  be  at  once  tied,  and  the  child  re- 
moved from  the  mother;  for  the  final  uterine  contractions  have  so 
completely  arrested  the  utero-placental  circulation,  as  to  render  it  no 
longer  of  any  value.  If  the  face  be  very  livid,  a  few  drops  of  blood 
may  with  advantage  be  allowed  to  flow  from  the  cord  before  it  is 
tied,  with  the  view  of  relieving  the  embarrassed  circulation.  Very 
often  some  slight  stimulus,  such  as  one  or  two  sharp  slaps  on  the 
thorax,  or  rapidly  rubbing  the  body  with  brandy  poured  into  the 
palms  of  the  hands,  will  suffice  to  induce  respiration.  Failing  this, 
nothing  acts  so  well  as  the  sudden  and  instantaneous  application  of 
heat  and  cold.  For  this  purpose  extremely  hot  water  is  placed  in 
one  basin,  and  quite  cold  water  in  another.  Taking  the  child  by 
the  shoulders  and  legs,  it  should  be  dipped  for  a  single  moment  into 
the  hot  water,  and  then  into  the  cold;  and  these  alternate  applica- 
tions may  be  repeated  once  or  twice,  as  occasion  require?.  The 
effect  of  this  measure  is  often  very  marked,  and  I  have  frequently 
seen  it  succeed  when  prolonged  efforts  at  artificial  respiration  had 
been  made  in  vain. 

Artificial  Respiration. — If  these  means  fail,  an  endeavor  must  be 
at  once  made  to  carry  on  respiration  artificially.  The  Sylvester 
method  is,  on  the  whole,  that  which  is  most  easily  applied,  and,  on 
account  of  the  compressibility  of  the  thorax,  it  is  peculiarly  suitable 
for  infants.  The  child  being  laid  on  its  back,  with  the  shoulders 
slightly  elevated,  the  elbows  are  grasped  by  the  operator,  and  alter- 
nately raised  above  the  head,  and  slowly  depressed  against  the  sides 
of  the  thorax,  so  as  to  produce  the  effect  of  inspiration  and  expiration. 
If  this  do  not  succeed,  the  Marshall  Hall  method  may  be  substituted; 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  535 

and  one  or  more  of  the  plans  of  exciting  reflex  action  through  the 
cutaneous  nerves  may  be  alternated  with  it. 

Insufflation  of  the  Lunys. — Other  means  of  exciting  respiration  have 
been  recommended.  One  of  them,  much  used  abroad,  is  the  artificial 
insufflation  of  the  lungs  by  means  of  a  flexible  catheter  guided  into 
the  glottis.  It  is  not  difficult  to  pass  the  end  of  a  catheter  into  the 
glottis,  using  the  little  finger  as  a  guide;  and  once  in  position,  it  may 
be  used  to  blow  air  gently  into  the  lungs,  which  is  expelled  by  com- 
pression on  the  thorax,  the  insufflation  being  repeated  at  short  inter- 
vals of  about  ten  seconds.  One  advantage  of  this  plan  is,  that  it 
allows  the  liquor  amnii  and  other  fluids,  which  may  have  been 
drawn  into  the  lungs  in  the  premature  efforts  at  respiration  before 
birth,  to  be  sucked  up  into  the  catheter,  and  so  removed  from  the 
lungs.  The  same  effect  may  be  produced,  but  less  perfectly,  by 
placing  the  hand  over  the  nostrils  of  the  child,  blowing  into  its 
mouth,  and  immediately  afterwards  compressing  the  thorax.1  One 
of  these  methods  should  certainly  be  tried,  if  all  other  means  have 
failed.  Faradization  along  the  course  of  the  phrenic  nerves  is  a 
promising  means  of  inducing  respiration,  which  should  be  used  if 
the  proper  apparatus  can  be  procured.  Encouragement  to  persevere 
in  our  endeavors  to  resuscitate  the  child  may  be  derived  from  the 
numerous  authenticated  instances  of  success  after  the  lapse  of  a 
considerable  time,  even  of  an  hour  or  more.  As  long  as  the  cardiac 
pulsations  continue,  however  feebly,  there  is  no  reason  to  despair. 

Washing  and  Dressing  of  the  Child. — When  the  child  cries  lustily 
from  the  first,  it  is  customary  for  the  nurse  to  wash  and  dress  it  as 
soon  as  her  immediate  attendance  on  the  mother  is  no  longer  required. 
For  this  purpose  it  is  placed  in  a  bath  of  warm  water,  and  carefully 
soaped  and  sponged  from  head  to  foot.  With  the  view  of  facilitating 
the  removal  of  the  unctuous  material  with  which  it  is  covered,  it  is 
usual  to  anoint  it  with  cold  cream  or  olive-oil,  which  is  washed  off 
in  the  bath.  Nurses  are  apt  to  use  undue  roughness  in  endeavoring 
to  remove  every  particle  of  the  vernix  caseosa,  small  portions  of 
which  are  often  firmly  adherent.  This  mistake  should  be  avoided,  as 
these  particles  will  soon  dry  up  and  become  spontaneously  detached. 
The  cord  is  generally  wrapped  in  a  small  piece  of  charred  linen, 
which  is  supposed  to  have  some  slight  antiseptic  property,  and  this 
is  renewed  from  day  to  day  until  the  cord  has  withered  and  separated. 
This  generally  occurs  within  a  week  :  and  a  small  pad  of  soft  linen  is 
then  placed  over  the  umbilicus,  and  supported  by  a  flannel  belly- 
band,  placed  round  the  abdomen,  which  should  not  be  too  tight,  for 
fear  of  embarrassing  the  respiration.  By  this  means  the  tendency 
to  umbilical  hernia  is  prevented.  [Many  obstetricians  have  adopted 
the  plan  in  our  country  of  cleaning  the  child  at  the  first  dressing 
without  water.  Grease  is  well  applied,  and  the  body  carefully  wiped 

['  When  this  is  done  the  oesophagus  must  be  closed  by  placing  the  thumb  and 
fingers  on  opposite  sides  of  the  larynx,  and  pressing  it  backward,  just  before  blowing 
in  the  mouth.  When  this  is  accomplished  so  as  to  fill  the  lungs,  the  thorax  should 
be  pressed,  and  the  inflation  repeated. — ED.] 


536  THE    PUERPERAL    STATE.. 

from  head  to  foot  with  soft  rags,  until  the  skin  is  cleansed  of  every- 
thing but  a  slight  oily  trace,  not  sufficient  to  soil  the  clothing.  This 
makes  the  skin  soft,  and  the  child  is  in  less  danger  of  taking  cold 
than  when  soap  and  water  are  used. — ED.] 

Clothing,  etc. — The  clothing  of  the  infant  varies  according  to  fashion 
and  the  circumstances  of  the  parents.  The  important  points  to  bear 
in  mind  are  that  it  should  be  warm  (since  newly-born  children  are 
extremely  susceptible  to  cold),  and  at  the  same  time  light,  and  suffi- 
ciently loose  to  allow  free  play  to  the  limbs  and  thorax.  All  tight 
bandaging  and  swaddling,  such  as  is  so  common  in  some  parts  of  the 
Continent,  should  be  avoided,  and  the  clothes  should  be  fastened  by 
strings  or  by  sewing,  and  no  pins  used.  At  the  present  day  it  is 
customary  not  to  use  caps,  so  that  the  head  may  be  kept  cool.  The 
utmost  possible  attention  should  be  paid  to  cleanliness,  and  the  child 
should  be  regularly  bathed  in  tepid  water,  at  first  once  daily,  and, 
after  the  first  few  weeks,  both  night  and  morning.  After  drying, 
the  flexures  of  the  thighs  and  arms,  and  the  nates,  should  be  dusted 
with  violet  powder  or  Fuller's  earth,  to  prevent  chafing  of  the  skin. 
The  excrements  should  be  received  in  napkins  wrapped  round  the 
hips,  and  great  care  is  required  to  change  the  napkins  as  often  as 
they  are  wet  or  soiled,  otherwise  troublesome  irritation  will  arise. 
A  neglect  of  this  precaution,  and  the  washing  of  the  napkins  with 
coarse  soap  or  soda,  are  among  the  principal  causes  of  the  eruptions 
and  excoriations  so  common  in  badly  cared  for  children.  When 
washed  and  dressed  the  child  may  be  placed  in  its  cradle,  and  covered 
with  soft  blankets  or  an  eider-brown  quilt. 

Application  of  the  Child  to  the  Breast. — As  soon  as  the  mother  has 
rested  a  little,  it  is  advisable  to  place  the  child  to  the  breast.  This 
is  useful  to  the  mother  by  favoring  uterine  contraction.  Even  now 
there  is  in  the  breasts  a  variable  quantity  of  the  peculiar  fluid  known 
as  colostrum.  This  is  a  viscid  yellowish  secretion,  different  in  appear- 
ance from  the  thin  bluish  milk  which  is  subsequently  formed.  Ex- 
amined under  the  microscope  it  is  found  to  contain  some  milk 
globules,  a  number  of  large  granular  and  small  fat  corpuscles.  It 
has  a  purgative  property,  and  soon  produces,  with  less  irritation 
than  any  of  the  laxatives  so  generally  used,  a  discharge  of  the  meco- 
nium  with  which  the  bowels  are  loaded.  Hence  the  accoucheur 
should  prohibit  the  common  practice  of  administering  castor  oil,  or 
other  aperient,  within  the  first  few  days  after  birth,  although  there 
can  be  no  objection  to  it,  in  special  cases,  if  the  bowels  appear  to  act 
inefficiently  and  with  difficulty. 

Over-frequent  Suckling  should  be  Avoided. — For  the  first  few  days, 
and  until  the  secretion  of  milk  is  thoroughly  established,  the  child 
should  be  put  to  the  breast  at  long  intervals  only.  Constant  attempts 
at  suckling  an  empty  breast  lead  to  nothing  but  disappointment,  both 
to  the  mother  and  child,  and,  by  unduly  irritating  the  mammae,  some- 
times to  positive  harm.  Therefore,  for  the  first  day  or  two,  it  is 
sufficient  if  the  child  be  applied  to  the  breast  twice,  or  at  most  three 
times,  in  the  twenty-four  hours.  Nor  is  it  necessary  to  be  apprehen- 
sive, as  many  mothers  naturally  are,  that  the  chilcl  will  suffer  from 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  537 

want  of  food.  A  few  spoonfuls  of  milk  and  water  being  given  from 
time  to  time,  the  child  may  generally  wait  without  injury  until  the 
milk  is  secreted.  This  is  generally  about  the  third  day,  when  the 
secretion  is  found  to  be  a  whitish  fluid,  more  watery  in  appearance 
than  cow's  milk,  and  showing  under  the  microscope  an  abundance 
of  minute  spherical  globules,  refracting  light  strongly,  which  are 
abundant  in  proportion  to  the  quality  of  the  milk.  A  certain  number 
of  granular  corpuscles  may  also  be  observed  shortly  after  the  birth 
of  the  child,  but,  after  the  first  month,  these  should  have  almost 
altogether  disappeared.  The  reaction  of  human  rnilk  is  decidedly 
alkaline,  and  the  taste  much  sweeter  than  that  of  cow's  milk. 

Importance  of  Nursing  when  Practicable. — The  importance  to  the 
mother  of  nursing  her  own  child,  whenever  her  health  permits,  on 
account  of  the  favorable  influence  of  lactation  in  promoting  a  proper 
involution  of  the  uterus,  has  already  been  insisted  on.  Unless  there 
be  some  positive  contra-indication,  such  as  a  marked  strumous 
cachexia,  an  hereditary  phthisical  tendency,  or  great  general  debil- 
ity, it  is  the  duty  of  the  accoucheur  to  urge  the  mother  to  attempt 
lactation,  even  if  jt  be  not  carried  on  more  than  a  month  or  two.  It 
is,  however,  the  fact  that  in  the  upper  classes  of  society  a  large 
number  of  patients  are  unable  to  nurse,  even  though  willing  and 
anxious  to  do  so.  In  some  there  is  hardly  any  lacteal  secretion  at 
all,  in  others  there  is  at  first  an  over-abundance  of  watery  and  innu- 
tritious  milk,  which  floods  the  breasts,  and  soon  dies  away  altogether. 

[Milk  Diet  for  the  Mother. — Many  can  be  enabled  to  nurse  well  by 
being  largely  fed  with  milk,  the  allowance  gradually  increased  with 
the  age  of  the  child.  One  of  our  patients  of  86  pounds  weight,  took 
2  quarts  daily,  and  gained  19  pounds.  She  had  failed  on  three 
former  occasions  in  a  month,  but  on  this  one  nursed  18  months. — ED.] 

When  the  Mother  cannot  Nurse  a  Wet  Nurse  should  be  Procured. — 
Whenever  the  mother  cannot  or  will  not  nurse,  the  question  will 
arise  as  to  the  method  of  bringing  up  the  child.  From  many  causes 
there  is  an  increasing  tendency  to  resort  to  bottle-feeding,  instead  of 
procuring  the  services  of  a  wet  nurse,  even  when  the  question  of 
expense  does  not  come  into  consideration.  No  long  experience  is 
required  to  prove  that  hand  feeding  is  a  bad  and  imperfect  substitute 
for  nature's  mode,  and  one  which  the  practitioner  should  discourage 
whenever  it  lies  in  his  power  to  do  so.1  It  is  true  that,  in  many 
cases,  bottle-fed  children  do  well ;  but  there  is  good  reason  to  believe 
that,  even  when  apparently  most  successful,  the  children  are  not  so 
strong  in  after-life  as  they  would  have  been  had  they  been  brought 
up  at  the  breast.  When,  in  addition,  it  is  borne  in  mind  how  much 
of  the  success  of  hand  feeding  depends  on  intelligent  care  on  the 
part  of  the  nurse,  what  evils  are  apt  to  accrue  from  injurious  selec- 
tion of  food,  and  from  ignorance  of  the  commonest  laws  of  dietetics, 
there  is  abundant  reason  for  urging  the  substitution  of  a  wet  nurse, 
whenever  the  mother  is  unable  to  undertake  the  suckling  of  her 

['  There  is  no  country  in  which  this  is  more  realized  than  our  own,  where  cholera 
infantum  is  so  prevalent. — ED.] 
35 


538  THE    PUERPERAL    STATE. 

child.  It  must  be  admitted  that  good  hand-feeding  is  better  than 
bad  wet  nursing,  and  the  success  of  the  latter  hinges  on  the  proper 
selection  of  a  wet  nurse.  As  this  falls  within  the  duties  of  the  prac- 
titioner, it  will  be  well  to  point  out  the  qualities  which  should  be 
sought  for  in  a  wet  nurse,  before  proceeding  to  discuss  the  mode  of 
rearing  the  child  at  the  breast. 

Selection  of  a  Wet  Nurse. — In  selecting  a  wet  nurse  we  should  en- 
deavor to  choose  a  strong,  healthy  woman,  who  should  not  be  over 
30,  or  35  years  of  age  at  the  outside,  since  the  quality  of  the  milk 
deteriorates  in  women  who  are  more  advanced  in  life.  For  a  similar 
reason  a  very  young  woman  of  16  or  17  should  be  rejected.  It  is 
needless  to  say  that  care  must  be  taken  to  ascertain  the  absence  of 
all  traces  of  constitutional  disease,  especially  marks  of  scrofula,  or 
enlarged  cervical  or  inguinal  glands,  which  may  possibly  be  due  to 
antecedent  syphilitic  taint.  If  the  nurse  be  of  good  muscular  de- 
velopment, healthy-looking,  with  a  clear  complexion,  and  sound 
teeth  (indicating  a  generally  good  state  of  health),  the  color  of  the 
hair  and  eyes  are  of  secondary  importance.  It  is  commonly  stated 
that  brunettes  make  better  nurses  than  blondes,  but  this  is  by  no 
means  necessarily  the  case ;  and,  provided  all  the  other  points  be  favor- 
able, fairness  of  skin  and  hair  need  be  no  bar  to  the  selection  of  a 
nurse.  The  breasts  should  be  pear-shaped,  rather  firm,  as  indicating 
an  abundance  of  gland-tissue,  and  with  the  superficial  veins  well 
marked.  Large,  flabby  breasts  owe  much  of  their  size  to  an  undue 
deposit  of  fat,  and  are  generally  unfavorable.  The  nipple  should  be 
prominent,  not  too  large,  and  free  from  cracks  and  erosions,  which, 
if  existing,  might  lead  to  subsequent  difficulties  in  nursing.  On 
pressing  the  breast  the  milk  should  flow  from  it  easily  in  a  number 
of  small  jets,  and  some  of  it  should  be  preserved  for  examination. 
It  should  be  of  a  bluish-white  color,  and  when  placed  under  the 
microscope,  the  field  should  be  covered  with  an  abundance  of  milk 
corpuscles,  and  the  large  granular  corpuscles  of  the  colostrum  should 
have  entirely  disappeared.  If  the  latter  be  observed  in  any  quantity 
in  a  woman  who  has  been  confined  five  or  six  weeks,  the  inference 
is  that  the  milk  is  inferior  in  quality.  It  is  not  often  that  the  prac- 
titioner has  an.  opportunity  of  inquiring  into  the  moral  qualities  of 
the  nurse,  although  much  ^valuable  information  might  be  derived 
from  a  knowledge  of  her  previous  character.  An  irascible,  excit- 
able, or  highly  nervous  woman  will  certainly  make  a  bad  nurse,  and 
the  most  trivial  causes  might  afterwards  interfere  with  the  quality 
of  her  milk.  Particular  attention  should  be  paid  to  the  nurse's  own 
child,  since  its  condition  affords  the  best  criterion  of  the  quality  of 
her  milk.  It  should  be  plump,  well  nourished,  and  free  from  all 
blemishes.  If  it  be  at  all  thin  and  wizened,  especially  if  there  be 
any  snuffling  at  the  nose,  or  should  any  eruption  exist  affording  the 
slightest  suspicion  of  a  syphilitic  taint,  the  nurse  should  be  unhesi- 
tatingly rejected. 

Management  of  Suckling. — The  management  of  suckling  is  much 
the  same  whether  the  child  is  nursed  by  the  mother  or  by  a  wet 
nurse.  As  soon  as  the  supply  of  milk  is  sufficiently  established, 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  539 

the  child  must  be  put  to  the  breast  at  short  intervals,  at  first  of  about 
two  hours,  and,  in  about  a  month  or  six  weeks,  of  three  hours.  From 
the  first  few  days  it  is  a  matter  of  the  greatest  importance,  both 
to  the  mother  and  child,  to  acquire  regular  habits  in  this  respect. 
If  the  mother  get  into  the  way  of  allowing  the  infant  to  take  the 
breast  whenever  it  cries,  as  a  means  of  keeping  it  quiet,  her  own 
health  must  soon  suffer,  to  say  nothing  of  the  discomfort  of  being 
incessantly  tied  to  the  child's  side ;  while  the  child  itself  has  not 
sufficient  rest  to  digest  its  food,  and,  very  shortly,  diarrhoea,  or  other 
symptoms  of  dyspepsia,  are  pretty  sure  to  follow.  After  a  month  or 
two  the  infant  should  be  trained  to  require  the  breast  less  often  at 
night,  so  as  to  enable  the  mother  to  have  an  undisturbed  sleep  of  six 
or  seven  hours.  For  this  purpose  she  should  arrange  the  times  of 
nursing  so  as  to  give  the  breast  just  before  she  goes  to  bed,  and  not 
again  until  the  early  morning.  If  the  child  should  require  food  in 
the  interval,  a  little  rnilk  and  water,  from  the  bottle,  may  be  advan- 
tageously given. 

Diet  of  Nursing  Women. — The  diet  of  the  nursing  woman  should  be 
arranged  on  ordinary  principles  of  hygiene.  It  should  be  abundant, 
simple,  and  nutritious,  and  all  rich  and  stimulating  articles  of  food 
should  be  avoided.  A  common  error  in  the  diet  of  wet  nurses  is 
over-feeding,  which  constantly  leads  to  deterioration  of  the  milk. 
Many  of  these  women,  before  entering  on  their  functions,  have  been 
living  on  the  simplest  and  even  sparest  diet,  and  not  uncommonly, 
in  the  better  class  of  houses,  they  are  suddenly  given  heavy  meat 
meals  three  and  even  four  times  a  day,  and  often  three  or  four  glasses 
of  stout.  It  is  hardly  a  matter  of  astonishment  that,  under  such  cir- 
cumstances, their  milk  should  be  found  to  disagree.  For  a  nursing 
woman  in  good  health  two  good  meat  meals  a  day,  with  two  glasses 
of  beer  or  porter,  and  as  much  milk  and  bread  and  butter  as  she 
likes  to  take  in  the  interval,  should  be  amply  sufficient.1  Plenty  of 
moderate  exercise  should  be  taken,  and  the  more  nurse  and  child  are 
out  in  the  open  air,  provided  the  weather  be  reasonably  fine,  the 
better  it  is  for  both. 

Signs  of  Successful  Lactation. — Carried  on  methodically  in  this 
manner,  wet  nursing  should  give  but  little  trouble.  In  the  intervals 
between  its  meals  the  child  sleeps  most  of  its  time,  and  wakes  with 
regularity  to  feed;  but  if  the  child  be  wakeful  and  restless,  cry  after 
feeding,  have  disordered  bowels,  and,  above  all,  if  it  do  not  gain, 
week  by  week,  in  weight  (a  point  which  should  be,  from  time  to 
time,  ascertained  by  the  scales),  we  may  conclude  that  there  is  either 
some  grave  defect  in  the  management  of  suckling,  or  that  the  milk 
is  not  agreeing.  Should  this  unsatisfactory  progress  continue,  in  spite 
of  our  endeavors  to  remedy  it,  there  is  no  resource  left  but  the  alter- 
ation of  the  diet,  either  by  changing  the  nurse,  or  by  bringing  up 
the  child  by  hand.  The  former  should  be  preferred  whenever  it  is 

['  A  wet  nurse  should  with  us  have  three  regular  meals,  no  stimulants  at  all;  milk 
to  drink  if  needed;  moderate  exercise,  and  be  taught  to  nurse  at  regular  intervals. — 
ED.] 


540  THE    PUERPERAL    STATE. 

practicable,  and,  in  the  upper  ranks  of  life,  it  is  by  no  means  rare  to 
have  to  change  the  wet  nurse  two  or  three  times,  before  one  is  met 
with  whose  milk  agrees  perfectly.  If  the  child  have  reached  six  or 
seven  months  of  age,  it  may  be  preferable  to  wean  it  altogether, 
especially  if  the  mother  have  nursed  it,  as  hand-feeding  is  much 
less  objectionable  if  the  infant  have  had  the  breast  for  even  a  few 
months. 

Period  of  Weaning. — As  a  rule,  weaning  should  not  be  attempted 
until  dentition  is  fairly  established,  that  being  the  sign  that  nature 
has  prepared  the  child  for  an  alteration  of  food;  and  it  is  better  that 
the  main  portion  of  the  diet  should  be  breast  milk  until  at  least  six 
or  seven  teeth  have  appeared.  This  is  a  safer  guide  than  any  arbi- 
trary rule  taken  from  the  age  of  the  child,  since  the  commencement 
of  dentition  varies  much  in  different  cases.  About  the  sixth  or 
seventh  month  it  is  a  good  plan  to  commence  the  use  of  some  suita- 
ble artificial  food  once  a  day,  so  as  to  relieve  the  strain  on  the  mother 
or  nurse,  and  prepare  the  child  for  weaning,  which  should  always  be 
a  very  gradual  process.  In  this  way  a  meal  of  rusks,  of  the  entire 
wheat  flour,  or  of  beef-  or  chicken-tea,  with  bread  crumb  in  it,  may 
be  given  with  advantage ;  and,  as  the  period  for  weaning  arrives,  a 
second  meal  may  be  added,  and  so  eventually  the  child  may  be  weaned 
without  distress  to  itself,  or  trouble  to  the  nurse. 

The  Disorders  of  Lactation. — The  disorders  of  lactation  are  nume- 
rous, and,  as  they  frequently  come  under  the  notice  of  the  practitioner, 
it  is  necessary  to  allude  to  some  of  the  most  common  and  important. 

Means  of  Arresting  the  Secretion  of  Milk. — The  advice  of  the  accou- 
cheur is  often  required  in  cases  in  which  it  has  been  determined  that 
the  patient  is  not  to  nurse,  when  we  desire  to  get  rid  of  the  milk  as 
soon  as  possible,  or  when,  at  the  time  of  weaning,  the  same  object  is 
sought.  The  extreme  heat  and  distension  of  the  breasts,  in  the  former 
class  of  cases,  often  give  rise  to  much  distress.  A  smart  saline  ape- 
rient will  aid  in  removing  the  milk,  and  for  this  purpose  a  double 
Seidlitz  powder,  or  frequent  small  doses  of  sulphate  of  magnesia,  act 
well;  while,  at  the  same  time,  the  patient  should  be  advised  to  take 
as  small  a  quantity  of  fluid  as  possible.  Iodide  of  potassium  in  large 
doses,  of  20  or  25  grains,  repeated  twice  or  thrice,  has  a  remarkable 
eft'ect  in  arresting  the  secretion  of  milk.  This  observation  was  first 
empirically  made  by  observing  that  the  secretion  of  .milk  was  arrested 
when  this  drug  was  administered  for  some  other  cause,  and  I  have 
frequently  found  it  answer  remarkably  well.  The  distension  of  the 
breasts  is  best  relieved  by  covering  them  with  a  layer  of  lint  or  cotton 
wool,  soaked  in  a  spirit  lotion,  or  eau  de  cologne  and  water,  over 
which  oiled  silk  is  placed,  and  by  directing  the  nurse  to  rub  them 
gently  with  warm  oil,  whenever  they  get  hard  and  lumpy.  Breast- 
pumps  and  similar  contrivances  only  irritate  the  breasts,  and  do  more 
harm  than  good.  The  local  application  of  belladonna  has  been  strongly 
recommended  as  a  means  for  preventing  lacteal  secretion.  As  usually 
applied,  in  the  form  of  belladonna  plaster,  it  is  likely  to  prove 
hurtful,  since  the  breast  often  enlarges  after  the  plasters  are  applied, 
and  the  pressure  of  the  unyielding  leather  on  which  they  are  spread 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  541 

produces  intense  suffering.  A  better  way  of  using  it  is  by  rubbing 
down  a  drachm  of  the  extract  of  belladonna  witli  an  ounce  of  glyce- 
rine, and  applying  this  on  lint.  In  some  cases  it  answers  extremely 
well ;  but  it  is  very  uncertain  in  its  action,  and  frequently  is  quite 
useless. 

Defective  Secretion  of  Milk. — A  deficiency  of  milk  in  nursing 
mothers  is  a  very  common  course  of  difficulty.  In  a  wet  nurse  this 
drawback  is,  of  cause,  an  indication  for  changing  the  nurse ;  but  to 
the  mother  the  importance  of  nursing  is  so  great,  that  an  endeavor 
must  be  made  either  to  increase  the  flow  of  milk,  or  to  supplement  it 
by  other  food.  Unfortunately,  little  reliance  can  be  placed  on  any  of 
the  so-called  galactagogues.  The  only  one  which  in  recent  times  has 
attracted  attention  is  the  leaves  of  the  castor  oil  plant,  which,  made 
into  poultices  and  applied  to  the  breast,  are  said  to  have  a  beneficial 
effect  in  increasing  the  flow  of  milk.1  More  reliance  must  be  placed 
in  a  sufficiency  of  nutritious  food,  especially  such  as  contains  phos- 
phatic  elements ;  stewed  eels,  oysters,  and  other  kinds  of  shell-fish, 
and  the  Ee-valenta  Arabica,  are  recommended  by  Dr.  Eouth,  who 
has  paid  some  attention  to  this  point,2  as  peculiarly  appropriate.  If 
the  amount  of  milk  be  decidedly  deficient,  the  child  should  be  less 
often  applied  to  the  breast,  so  as  to  allow  milk  to  collect,  and  pro- 
perly prepared  cow's  rnilk  from  a  bottle  should  be  given  alternately 
with  the  breast.  This  mixed  diet  generally  answers  well,  and  is  far 
preferable  to  pure  hand-feeding. 

Depressed  Nipples. — A  not  uncommon  source  of  difficulty  is  a  de- 
pressed condition  of  the  nipples,  which  is  generally  produced  by  the 
constant  pressure  of  the  stays.  The  result  is,  that  the  child,  unable 
to  grasp  the  nipple,  and  wearied  with  ineffectual  efforts,  may  at  last 
refuse  the  breast  altogether.  An  endeavor  should  be  made  to  elon- 
gate the  nipple  before  putting  it  into  the  child's  mouth,  either  by  the 
ringers,  or  by  some  form  of  breast-pump,  which  here  finds  a  useful 
indication.  In  the  worst  class  of  cases,  when  the  nipple  is  perma- 
nently depressed,  it  may  be  necessary  to  let  the  child  suck  through 
a  glass  nipple-shield,  to  which  is  attached  an  india-rubber  tube, 
similar  to  that  of  a  sucking-bottle ;  this  it  is  generally  well  able 
to  do. 

Fissures  and  excoriations  of  the  nipples  are  common  causes  of  suf- 
fering, in  some  cases  leading  to  mammary  abscess.  Whenever  the 
practitioner  has  the  opportunity,  he  should  advise  his  patient  to 
prepare  the  nipple  for  nursing  in  the  latter  months  of  pregnancy; 
and  this  may  best  be  done  by  daily  bathing  it  with  a  spirituous  or 
astringent  lotion,  such  as  eau  de  cologne  and  water,  or  a  weak  solu- 
tion of  tannin.  After  nursing  has  begun,  great  care  should  be  taken 
to  wash  and  dry  the  nipple  after  the  child  has  been  applied  to  it,  and, 
as  long  as  the  mother  is  in  the  recumbent  position,  she  may,  if  the 

1  [Where  milk  agrees  with  the  mother,  it  exceeds  in  virtue  all  other  forms  of  diet. 
See  article  entitled  "  Milk  as  a  Diet  during  Lactation,"  in  Amer.  Journ.  of  Obstet- 
rics, Feb.  1870,  p.  675,  by  ED.] 

2  Routh,  On  Infant-feeding. 


542  THE    PUERPERAL    STATE. 

nipples  be  at  all  tender,  use  zinc  nipple-shields  with  advantage,  when 
she  is  not  nursing.  In  this  way  these  troublesome  complications  may 
generally  be  prevented.  The  most  common  forms  are  either  an  abra- 
sion on  the  surface  of  the  nipple,  which,  if  neglected,  may  form  a 
small  ulcer,  or  a  crack  at  some  part  of  the  nipple,  most  generally  at 
its  base.  In  either  case,  the  suffering  when  the  child  is  put  to  the 
breast  is  intense,  sometimes  indeed  amounting  to  intolerable  anguish, 
causing  the  mother  to  look  forward  with  dread  to  the  application  of 
the  child.  Whenever  such  pain  is  complained  of,  the  nipple  should 
be  carefully  examined,  since  the  fissure  or  sore  is  often  so  minute  as 
to  escape  superficial  examination.  The  remedies  recommended  are 
very  numerous,  and  not  always  successful.  Amongst  those  most 
commonly  used  are  astringent  applications,  such  as  tannin,  or  weak 
solutions  of  nitrate  of  silver,  or  cauterizing  the  edges  of  the  fissure 
with  the  solid  nitrate  of  silver,  or  applying  the  flexible  collodion  of 
the  Pharmacopoeia.  Dr.  Wilson,  of  Glasgow,  speaks  highly  of  a 
lotion  composed  of  ten  grains  of  nitrate  of  lead  in  an  ounce  of  gly- 
cerine, which  is  to  be  applied  after  suckling,  the  nipple  .being  care- 
fully washed  before  the  child  is  again  put  to  the  breast.  I  have 
myself  found  nothing^  answer  so  well  as  a  lotion  composed  of  half  an 
ounce  of  sulphurous  acid,  half  an  ounce  of  the  glycerine  of  tannin, 
and  an  ounce  of  water,  the  beneficial  effects  of  which  are  sometimes 
quite  remarkable.  Belief  may  occasionally  be  obtained  by  inducing 
the  child  to  suck  through  a  nipple-shield,  especially  when  there  is 
only  an  excoriation ;  but  this  will  not  always  answer,  on  account  of 
the  extreme  pain  which  it  produces. 

Excessive  Flow  of  Milk. — An  excessive  flow  of  milk,  known  as 
galactorrhoea,  often  interferes  with  successful  lactation.  It  is  by  no 
means  rare  in  the  first  weeks  after  delivery  for  women  of  delicate 
constitution,  who  are  really  unfit  to  nurse,  to  be  flooded  with  a  super- 
abundance of  watery  and  innutritions  milk,  which  soon  produces 
disordered  digestion  in  the  child.  Under  such  circumstances,  the 
only  thing  to  be  done  is  to  give  up  an  attempt  which  is  injurious 
both  to  the  mother  and  child.  At  a  later  stage  the  milk,  secreted  in 
large  quantities,  is  sufficiently  nourishing  to  the  child,  but  the  drain 
on  the  mother's  constitution  soon  begins  to  tell  on  her.  Palpitation, 
giddiness,  emaciation,  headache,  loss  of  sleep,  spots  before  the  eyes, 
and  even  amaurosis,  indicate  the  serious  effects  which  are  being  pro- 
duced, and  the  absolute  necessity  of  at  once  stopping  lactation.  When- 
ever, therefore,  a  nursing  woman  suffers  from  such  symptoms,  it  is 
far  better  at  once  to  remove  the  cause,  otherwise  a  very  serious  and 
permanent  deterioration  of  health  might  result. 

Mammary  Abscess. — There  is  no  more  troublesome  complication  of 
lactation  than  the  formation  of  abscess  in  the  breast ;  an  occurrence 
by  no  means  rare,  and  which,  if  improperly  treated,  may,  by  long- 
continued  suppuration  and  the  formation  of  numerous  sinuses  in  and 
about  the  breast,  produce  very  serious  effects  on  the  general  health. 
The  causes  of  breast  abscess  are  numerous,  and  very  trivial  circum- 
stances may  occasionally  set  up  inflammation,  ending  in  suppuration. 
Thus  it  may  follow  exposure  to  cold;  a  blow,  or  other  injury  to  the 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  543 

breast;  some  temporary  engorgement  of  the  lacteal  tubes;  or  even 
sudden  or  depressing  mental  emotions.  The  most  frequent  cause  is 
irritation  from  fissures  or  erosions  of  the  nipples,  which  must,  there- 
fore, always  be  regarded  with  suspicion,  and  cured  as  soon  as  possible. 

Signs  and  Symptoms. — The  abscess  may  form  in  any  part  of  the 
breast,  or  in  the  areolar  tissue  below  it ;  in  the  latter  case,  the  in- 
flammation very  generally  extends  to  the  gland  structure.  Abscess 
is  usually  ushered  in  by  constitutional  symptoms,  varying  in  severity 
with  the  amount  of  the  inflammation.  Pyrexia  is  always  present ; 
elevated  temperature,  rapid  pulse,  and  much  malaise  and  sense  of 
feverishness,  followed,  in  many  cases,  by  distinct  rigor,  when  deep- 
seated  suppuration  is  taking  place.  On  examining  the  breast  it  will 
be  found  to  be  generally  enlarged  and  very  tender,  while,  at  the  site 
of  the  abscess,  an  indurated  and  painful  swelling  may  be  felt.  If  the 
inflammation  be  chiefly  limited  to  the  subglandular  areolar  tissue, 
there  may  be  no  localized  swelling  felt,  but  the  whole  breast  will  be 
acutely  sensitive,  and  the  slightest  movement  will  cause  much  pain. 
As  the  case  progresses,  the  abscess  becomes  more  and  more  super- 
ficial, the  skin  covering  it  is  red  and  glazed,  and,  if  left  to  itself,  it 
bursts.  In  the  more  serious  cases,  it  is  by  no  means  rare  for  multiple 
abscesses  to  form.  These  opening,  one  after  the  other,  lead  to  the 
formation  of  numerous  fistulous  tracts,  by  which  the  breast  may  be- 
come completely  riddled.  Sloughing  of  portions  of  the  gland-tissue 
may  take  place,  and  even  considerable  hemorrhage,  from  the  de- 
struction of  bloodvessels.  The  general  health  soon  suffers  to  a 
marked  degree,  and,  as  the  sinuses  continue  to  suppurate  for  many 
successive  months,  it  is  by  no  means  uncommon  for  the  patient  to  be 
reduced  to  a  state  of  profound  and  even  dangerous  debility. 

Treatment. — Much  may  be  done  by  proper  care  to  prevent  the 
formation  of  abscess,  especially  by  removing  engorgement  of  the 
lacteal  ducts,  when  threatened,  by  gentle  hand  friction  in  the  manner 
already  indicated.  When  the  general  symptoms,  and  the  local  ten- 
derness, indicate  that  inflammation  has  commenced,  we  should  at 
once  endeavor  to  moderate  it,  in  the  hope  that  resolution  may  occur 
without  the  formation  of  pus.  Here  general  principles  must  be 
attended  to,  especially  giving  the  affected  part  as  much  rest  as  possi- 
ble. Feverishness  may  be  combated  by  gentle  saline,  minute  doses 
of  aconite,  and  large  doses  of  quinine  ;  while  pain  should  be  relieved 
by  opiates.  The  patient  should  be  strictly  confined  to  bed,  and  the 
affected  breast  supported  by  a  suspensory  bandage.  Warmth  and 
moisture  are  the  best  means  of  relieving  the  local  pain,  either  in  the 
form  of  hot  fomentations,  or  of  light  poultices  of  linseed-meal  or 
bread  and  milk,  and  the  breast  may  be  smeared  with  extract  of  bella- 
donna rubbed  down  with  glycerine,  or  the  belladonna  liniment 
sprinkled  over  the  surface  of  the  poultices.  Generally  the  pain  and 
irritation  produced  by  putting  the  child  to  the  breast  are  so  great  as 
to  centra-indicate  nursing  from  the  affected  side  altogether,  and  we 
must  trust  to  relieving  the  tension  by  poultices ;  suckling  being,  in 
the  mean  time,  carried  on  by  the  other  breast  alone.  In  favorable 
cases  this  is  quite  possible  for  a  time,  and  it  may  be  that,  if  the  in- 


544  THE    PUERPERAL    STATE. 

flammation  do  not  end  in  suppuration,  or  if  the  abscess  be  small  and 
localized,  the  affected  breast  is  again  able  to  resume  its  functions. 
Often  this  is  not  possible,  and  it  may  be  advisable,  in  severe  cases,  to 
give  up  nursing  altogether. 

Pus  should  le  Removed  as  soon  as  Possible. — The  subsequent  man- 
agement of  the  case  consists  in  the  opening  of  the  abscess  as  soon  as 
the  existence  of  pus  is  ascertained,  either  by  fluctuation,  or,  if  the 
site  of  the  abscess  be  deep-seated,  by  the  exploring  needle.  It  may 
be  laid  down  as  a  principle,  that  the  sooner  the  pus  is  evacuated  the 
better,  and  nothing  is  to  be  gained  by  waiting  until  it  is  superficial. 
On  the  contrary,  such  delay  only  leads  to  more  extensive  disorgani- 
zation of  tissue  and  the  further  spread  of  inflammation. 

Antiseptic  Treatment. — The  method  of  opening  the  abscess  is  of 
primary  importance.  It  has  always  been  customary  simply  to  open 
the  abscess  at  its  most  depending  part,  without  using  any  precaution 
against  the  admission  of  air,  and  afterwards  to  treat  secondary  ab- 
scesses in  the  same  way.  The  results  are  well  known  to  all  practical 
accoucheurs,  and  the  records  of  surgery  fully  show  how  many  weeks 
or  months  generally  elapse  in  bad  cases  before  recovery  is  complete. 
The  antiseptic  treatment  of  mammary  abscess;  in  the  way  first 
pointed  out  by  Lister,  afford  results  which  are  of  the  most  remark- 
able and  satisfactory  kind.  Instead  of  being  weeks  and  months  in 
healing,  I  believe  that  the  practitioner  who  fairly  and  minutely  car- 
ries out  Mr.  Lister's  directions  may  confidently  look  for  complete 
closure  of  the  abscess  in  a  few  days ;  and  I  know  nothing,  in  the 
whole  range  of  my  professional  experience,  that  has  given  me  more 
satisfaction  than  the  application  of  this  method  to  abscesses  of  the 
breast.  The  plan  I  first  used  is  that  recommended  by  Lister  in  the 
"  Lancet "  for  1867,  but  which  is  now  superseded  by  his  improved 
methods,  which,  of  course,  will  be  used  in  preference  by  all  who 
have  made  themselves  familiar  with  the  details  of  antiseptic  surgery. 
The  former,  however,  is  easily  within  the  reach  of  every  one,  and  is 
so  simple  that  no  special  skill  or  practice  is  required  in  its  applica- 
tion ;  whereas  the  more  perfected  antiseptic  appliances  will  probably 
not  be  so  readily  obtained,  and  are  much  more  difficult  to  use.  I, 
therefore,  insert  Mr.  Lister's  original  directions,  which  he  assures  me 
are  perfectly  aseptic,  for  the  guidance  of  those  who  may  not  be  able 
to  obtain  the  more  elaborate  dressings : — "  A  solution  of  one  part  of 
crystallized  carbolic  acid  in  four  parts  of  boiled  linseed-oil  having 
been  prepared,  a  piece  of  rag  from  four  to  six  inches  square  is  clipped 
into  the  oily  mixture,  and  laid  upon  the  skin  where  the  incision  is  to 
be  made.  The  lower  edge  of  the  rag  being  then  raised,  while  the 
upper  edge  is  kept  from  slipping  by  an  assistant,  a  common  scalpel 
or  bistoury  dipped  in  the  oil  is  plunged  into  the  cavity  of  the  ab- 
scess, and  an  opening  about  three-quarters  of  an  inch  in  length  is 
made,  and  the  instant  the  knife  is  withdrawn  the  rag  is  dropped 
upon  the  skin  as  an  antiseptic  curtain,  beneath  which  the  pus  flows 
out  into  a  vessel  placed  to  receive  it.  The  cavity  of  the  abscess  is 
firmly  pressed,  so  as  to  force  out  all  existing  pus  as  nearly  as  may  be 
(the  old  fear  of  doing  mischief  by  rough  treatment  of  the  pyogenic 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  545 

membrane  being  quite  ill-founded);  and  if  there  be  much  oozing  of 
blood,  or  if  there  be  considerable  thickness  of  parts  between  the 
abscess  and  the  surface,  a  piece  of  lint  dipped  in  the  antiseptic  oil  is 
introduced  into  the  incision  to  check  bleeding  and  prevent  primary 
adhesion,  which  is  otherwise  very  apt  to  occur.  The  introduction 
of  the  lint  is  effected  as  rapidly  as  may  be,  and  under  the  protection 
of  the  antiseptic  rag.  Thus  the  evacuation  of  the  original  contents 
is  accomplished  with  perfect  security  against  the  introduction  of 
living  germs.  This,  however,  would  be  of  no  avail  unless  an  anti- 
septic dressing  could  be  applied  that  would  effectually  prevent  the 
decomposition  of  the  stream  of  pus  constantly  flowing  out  beneath  it. 
After  numerous  disappointments,  I  have  succeeded  with  the  follow- 
ing, which  may  be  relied  upon  as  absolutely  trustworthy:  About 
six  teaspoonfuls  of  the  above-mentioned  solution  of  carbolic  acid  in 
linseed  oil  are  mixed  up  with  common  whiting  (carbonate  of  lime) 
to  the  consistence  of  a  firm  paste,  which  is,  in  fact,  glazier's  putty 
with  the  addition  of  a  little  carbolic  acid.  This  is  spread  upon  a 
piece  of  common  tin-foil  about  six  inches  square,  so  as  to  form  a 
layer  about  a  quarter  of  an  inch  thick.  The  tin-foil,  thus  spread 
with  putty,  is  placed  upon  the  skin,  so  that  the  middle  of  it  corre- 
sponds to  the  position  of  the  incision,  the  antiseptic  rag  used  in 
opening  the  abscess  being  removed  the  instant  before.  The  tin  is 
then  fixed  securely  by  adhesive  plaster,  the  lowest  edge  being  left 
free  for  the  escape  of  the  discharge  into  a  folded  towel  placed  over 
it  and  secured  by  a  bandage.  The  dressing  is  changed,  as  a  general 
rule,  once  in  24  hours,  but,  if  the  abscess  be  a  very  large  one,  it  is 
prudent  to  see  the  patient  12  hours  after  it  has  been  opened,  when, 
if  the  towel  should  be  much  stained  with  discharge,  the  dressing 
should  be  changed,  to  avoid  subjecting  its  antiseptic  virtues  to  too 
severe  a  test.  But  after  the  first  24  hours  a  single  daily  dressing 
is  sufficient.  The  changing  of  the  dressing  must  be  methodically 
done,  as  follows:  A  second  similar  piece  of  tin-foil  having  been 
spread  with  the  putty,  a  piece  of  rag  is  dipped  in  the  oily  solution 
and  placed  on  the  incision  the  moment  the  first  tin  is  removed.  This 
guards  against  the  possibility  df  mischief  occurring  during  the  cleans- 
ing of  the  skin  with  a  dry  cloth,  and  pressing  out  any  discharge 
which  may  exist  in  the  cavity.  If  a  plug  of  lint  was  introduced 
when  the  abscess  was  opened,  it  is  removed  under  cover  of  the  anti- 
septic rag,  which  is  taken  off  at  the  moment  \vhen  the  new  tin  is  to 
be  applied.  The  same  process  is  continued  daily  until  the  sinus 
closes." 

Treatment  of  Long -continued  Suppuration  and  Fever. — If  the  case 
come  under  our  care  when  the  abscess  has  been  long  discharging,  or 
when  sinuses  have  formed,  the  treatment  is  directed  mainly  to  pro- 
curing a  cessation  of  suppuration  and  closure  of  the  sinuses.  For 
this  purpose  methodical  strapping  of  the  breast  with  adhesive  plaster, 
so  as  to  afford  steady  support  and  compress  the  opposing  pyogenic 
surfaces,  will  give  the  best  results.  It  may  be  necessary  to  lay  open 
some  of  the  sinuses,  or  to  inject  tinct.  iodi  or  other  stimulating  lotions, 
so  as  to  moderate  the  discharge,  the  subsequent  surgical  treatment 


-546  THE    PUERPERAL    STATE. 

varying  according  to  the  requirements  of  each  case.  As  the  drain 
on  the  system  is  great,  and  the  constitutional  debility  generally  pro- 
nounced, much  attention  must  be  paid  to  general  treatment;  and 
abundance  of  nourishing  food,  appropriate  stimulants,  arid  such 
medicines  as  iron  and  quinine,  will  be  indicated. 

Hand-feeding. — In  a  considerable  number  of  cases  the  inability  of 
the  mother  to  nurse  the  child,  her  invincible  repugnance  to  a  wet 
nurse,  or  inability  to  bear  the  expense,  renders  hand-feeding  essen- 
tial. It  is,  therefore,  of  importance  that  the  accoucheur  should  be 
thoroughly  familiar  with  the  best  method  of  bringing  up  the  child 
by  hand,  so  as  to  be  able  to  direct  the  process  in  the  way  that  is 
most  likely  to  be  successful. 

Causes  of  Mortality  in  Hand-fed  Children. — Much  of  the  mortality 
following  hand-feeding  may  be  traced  to  unsuitable  food.  Among 
the  poorer  classes  especially  there  is  a  prevalent  notion  that  milk 
alone  is  insufficient;  and  hence  the  almost  universal  custom  of  ad- 
ministering various  farinaceous  foods  such  as  corn-flour  or  arrow- 
root, even  from  the  earliest  period.  Many  of  these  consist  of  starch 
alone,  and  are  therefore  absolutely  unsuited  for  forming  the  staple 
of  diet,  on  account  of  the  total  absence  of  nitrogenous  elements. 
Independently  of  this,  it  has  been  shown  that  the  saliva  of  infants 
has  not  the  same  digestive  property  on  starch  that  it  subsequently 
acquires,  and  this  affords  a  further  explanation  of  its  so  constantly 
producing  intestinal  derangement.  Eeason,  as  well  as  experience, 
abundantly  prove  that  the  object  to  be  aimed  at  in  hand-feeding  is 
to  imitate  as  nearly  as  possible  the  food  which  nature  supplies  for 
the  new-born  child,  and  therefore  the  obvious  course  is  to  Use  milk 
from  some  animal,  so  treated  as  to  make  it  resemble  human  milk 
as  nearly  as  may  be. 

Ass's  Milk. — Of  the  various  milks  used,  that  of  the  ass,  on  the 
whole,  most  closely  resembles  human  milk,  containing  less  casein 
and  butter,  and  more  saline  ingredients.  It  is  not  always  easy  to 
obtain,  and  in  towns  is  excessively  expensive.  Moreover,  it  does  not 
always  agree  with  the  child,  being  apt  to  produce  diarrhoea.  We 
can,  however,  be  more  certain  of  its  being  unadulterated,  which  in 
large  cities  is  in  itself  no  small  advantage,  and  it  may  be  given  with- 
out the  addition  of  water  or  sugar. 

Goafs  milk  in  this  country  is  still  more  difficult  to  obtain,  but  it 
often  succeeds  admirably.  In  many  places  the  infant  sucks  the  teat 
directly,  and  certainly  thrives  well  on  the  plan. 

Cow's  Milk  and  its  Preparation. — In  a  large  majority  of  cases  we 
have  to  rely  on  cow's  milk  alone.  It  differs  from  human  milk  in 
containing  less  water,  a  larger  amount  of  casein  and  solid  matters, 
and  less  sugar.  Therefore,  before  being  given,  it  requires  to  be 
diluted  and  sweetened.  A  common  mistake  is  over-dilution,  and  it 
is  far  from  rare  for  nurses  to  administer  one-third  cow's  milk  to  two- 
thirds  water.  The  result  of  this  excessive  dilution  is,  that  the  child 
becomes  pale  and  puny,  and  has  none  of  the  firm  and  plurnp  appear- 
ance of  a  well-fed  infant.  The  practitioner  should,  therefore,  ascer- 
tain that  this  mistake  is  not  being  made;  and  the  necessary  dilution 


MANAGEMENT    OF    THE    INFANT,    LACTATION,   ETC.  547 

will  be  best  obtained  by  adding  to  pure  fresh  cow's  milk,  one- third 
hot  water,  so  as  to  warm  the  mixture  to  about  96°,  the  whole  being 
slightly  sweetened  with  sugar  of  milk,  or  ordinary  crystallized  sugar. 
After  the  first  two  or  three  months  the  amount  of  water  may  be 
lessened,  and  pure  milk,  warmed  and  sweetened,  given  instead.1 
Whenever  it  is  possible,  the  milk  should  be  obtained  from  the  same 
cow,  and  in  towns  some  care  is  requisite  to  see  that  the  animal  is 
properly  fed  and  stabled.  Of  late  years  it  has  been  customary  to 
obviate  the  difficulties  of  obtaining  good  fresh  milk  by  using  some 
of  the  tinned  milks  now  so  easily  to  be  had.  These  are  already 
sweetened,  and  sometimes  answer  well,  if  not  given  in  too  weak  a 
dilution.  One  great  drawback  in  bottle-feeding  is  the  tendency  of 
the  milk  to  become  acid,  and  hence  to  produce  diarrhoea.  This  may 
be  obviated  to  a  great  extent  by  adding  a  tablespoonful  of  lime-water 
to  each  bottle,  instead  of  an  equal  quantity  of  water. 

Artificial  Human  Milk. — An  admirable  plan  of  treating  cow's  milk, 
so  as  to  reduce  it  to  almost  absolute  chemical  identity  with  human 
milk,  has  been  devised  by  Professor  Frankland,  to  whom  I  am  in- 
debted for  permission  to  insert  the  receipt.  I  have  followed  this 
method  in  many  cases,  and  find  it  far  superior  to  the  usual  one,  as 
it  produces  an  exact  and  uniform  compound.  With  a  little  practice 
nurses  can  employ  it  with  no  more  trouble  than  the  ordinary  mixing 
of  cow's  milk  with  water  and  sugar.  The  following  extract  from 
Dr.  Frankland's  work2  will  explain  the  principles  on  which  the  pre- 
paration of  the  artificial  human  milk  is  founded:  "The  rearing  of 
infants  who  cannot  be  supplied  with  their  natural  food  is  notoriously 
difficult  and  uncertain,  owing  chiefly  to  the  great  difference  in  the 
chemical  composition  of  human  milk  and  cow's  milk.  The  latter  is 
much  richer  in  casein  and  poorer  in  rnilk -sugar  than  the  former, 
whilst  asses'  milk,  which  is  sometimes  used  for  feeding  infants,  is 
too  poor  in  casein  and  butter,  although  the  proportion  of  sugar  is 
nearly  the  same  as  in  human  milk.  The  relations  of  the  three  kinds 
of  milk  to  each  other  are  clearly  seen  from  the  following  analytical 
numbers,  which  express  the  percentage  amounts  of  the  different 
constituents : — 

Woman.  Ass.  Cow. 

Casein 2.7  1.7  4.2 

Butter 3.5  1.3  3.8 

Milk-sugar 5.0  4.5  3.8 

Salts 2  .5  .7 

These  numbers  show  that  by  the  removal  of  one-third  of  the  casein 
from  cow's  milk  and  the  addition  of  about  one -third  more  milk-sugar, 
a  liquid  is  obtained  which  closely  approaches  human  milk  in  compo- 
sition, the  percentage  amounts  of  the  four  chief  constituents  being 
as  follows: — • 

['  The  milk  of  the  Alderney  row  is  too  rich  in  butter  for  a  young  infant.  Milk 
fr-om  one  cow  is  often  a  trick  of  the  vendor.  A  selected  animal  should  be  neither 
young  nor  old,  and  of  common  stock,  having  had  two  or  three  calves,  and  healthy. 
—ED.] 

2  Frankland's  Experimental  Researches  in  Chemistry,  p.  843. 


548  THE    PUERPERAL    STATE. 

Casein 2.8 

Butter 3.8 

Milk-sugar     ..........  5.0 

Salts      ...........  .7 

The  following  is  the  mode  of  preparing  the  milk :  Allow  one-third 
of  a  pint  of  new  milk  to  stand  for  about  twelve  hours,  remove  the 
cream,  and  add  to  it  two-thirds  of  a  pint  of  new  milk,  as  fresh  from, 
the  cow  as  possible.  Into  the  one-third  of  a  pint  of  blue  milk  left 
after  the  abstraction  of  the  cream  put  a  piece  of  rennet  about  one 
inch  square.  Set  the  vessel  in  warm  water  until  the  milk  is  fully 
curdled,  an  operation  requiring  from  five  to  fifteen  minutes,  accord- 
ing to  the  activity  of  the  rennet,  which  should  be  removed  as  soon 
as  the  curdling  commences,  and  put  into  an  egg-cup  for  use  on  sub- 
sequent occasions,  as  it  may  be  employed  daily  for  a  month  or  two. 
Break  up  the  curd  repeatedly,  and  carefully  separate  the  whole  of 
the  whey,  which  should  then  be  rapidly  heated  to  boiling  in  a  small 
tin  pan  placed  over  a  spirit  or  gas  lamp.  During  the  heating  a 
further  quantity  of  casein  technically  called  "fleetings"  separates, 
and  must  be  removed  by  straining  through  muslin.  Now  dissolve 
110  grains  of  powdered  sugar  of  milk  in  the  hot  whey,  and  mix  it 
with  the  two-thirds  of  a  pint  of  new  milk  to  which  the  cream  from 
the  other  third  of  a  pint  was  added  as  already  described.  The  arti- 
ficial milk  should  be  used  within  twelve  hours  of  its  preparation, 
and  it  is  almost  needless  to  add  that  all  the  vessels  employed  in  its 
manufacture  and  administration  should  be  kept  scrupulously  clean. 

Method  of  Hand-feeding . — Much  of  the  success  of  bottle-feeding 
must  depend  on  minute  care  and  scrupulous  cleanliness,  points  which 
cannot  be  too  strongly  insisted  on.  Particular  attention  should  be 
paid  to  preparing  the  food  fresh  for  every  meal,  and  to  keeping  the 
feeding-bottle  and  tubes  constantly  in  water  when  not  in  use,  so  that 
minute  particles  of  milk  may  not  remain  about  them  and  become 
sour.  A  neglect  of  this  is  one  of  the  most  fertile  sources  of  the 
thrush  from  which  bottle-fed  infants  often  suffer.  The  particular 
form  of  bottle  used  is  not  of  much  consequence.  Those  now  com- 
monly employed,  with  a  long  india-rubber  tube  attached,  are  prefer- 
able to  the  older  forms  of  flat  bottle,  as  they  necessitate  strong 
suction  on  the  part  of  the  infant,  thus  forcing  it  to  swallow  the  food 
more  slowly.  Care  must  be  taken  to  give  the  meals  at  stated  periods, 
as  in  breast-feeding,  and  these  should  be  at  first  about  two  hours 
apart,  the  intervals  being  gradually  extended.  The  nurse  should  be 
strictly  cautioned  against  the  common  practice  of  placing  the  bottle 
beside  the  infant  in  its  cradle,  and  allowing  it  to  suck  to  repletion,  a 
practice  which  leads  to  over-distension  of  the  stomach,  and  conse- 
quent dyspepsia.  The  child  should  be  raised  in  the  arms  at  the 
proper  time,  have  its  food  administered,  and  then  be  replaced  in  the 
cradle  to  sleep.  In  the  first  few  weeks  of  bottle-feeding  constipation 
is  very  common,  and  may  be  effectually  remedied  by  placing  as 
much  phosphate  of  soda  as  will  lie  on  a  threepenny-piece  in  the 
bottle,  two  or  three  times  in  the  twenty-four  hours. 


MANAGEMENT    OF    THE    INFANT,    LACTATION,    ETC.  549 

Other  kinds  of  Food. — If  this  system  succeed,  no  other  food  should 
be  given  until  the  child  is  six  or  seven  months  old,  and  then  some 
of  the  various  infant's  foods  may  be  cautiously  commenced.  Of  these 
there  are  an  immense  number  in  common  use  ;  some  of  which  are 
good  articles  of  diet,  others  are  unfitted  for  infants.  In  selecting 
them  we  have  to  see  that  they  contain  the  essential  elements  of  nutri- 
tion in  proper  combination.  All  those,  therefore,  that  are  purely 
starchy  in  character,  such  as  arrowroot,  corn-flour,  and  the  like, 
should  be  avoided ;  while  those  that  contain  nitrogenous  as  well  as 
starchy  elements,  may  be  safely  given.  Of  the  latter  the  entire 
wheat  flour,  which  contains  the  husks  ground  down  with  the  wheat, 
generally  answers  admirably ;  and  of  the  same  character  are  rusks, 
tops  and  bottoms,  Nestle's  or  Liebig's  infant's  food,  and  many  others. 
If  the  child  be  pale  and  flabby,  some  more  purely  animal  food  may 
often  be  given  twice  a  day,  and  great  benefit  may  be  derived  from  a 
single  meal  of  beef,  chicken,  or  veal  tea,  with  a  little  bread  crumb  in 
it,  especially  after  the  sixth  or  seventh  month.  Milk,  however,  should 
still  form  the  main  article  of  diet,  and  should  continue  to  do  so  for 
many  months. 

Management  ivlien  Milk  disagrees. — If  the  child  be  pale,  flabby,  and 
do  not  gain  flesh,  more  especially  if  diarrhoea  or  other  intestinal  dis- 
turbance be  present,  we  may  be  certain  that  hand-feeding  is  not  an- 
swering satisfactorily,  and  that  some  change  is  required.  If  the  child 
be  not  too  old,  and  will  still  take  the  breast,  that  is  certainly  the 
best  remedy,  but,  if  that  be  not  possible,  it  is  necessary  to  alter  the 
diet.  When  milk  disagrees,  cream,  in  the  proportion  of  one  table- 
spoonful  to  three  of  water,  sometimes  answers  well.  Occasionally 
also  Liebig's  infant's  food,  when  carefully  prepared,  renders  good 
service.  Too  often,  however,  when  once  diarrhoea  or  other  intesti- 
nal disturbance  has  set  in,  all  our  efforts  may  prove  unavailing,  and 
the  health,  if  not  the  life,  of  the  infant  becomes  seriously  imperilled. 
It  is  not,  however,  within  the  scope  of  this  work  to  treat  of  the  dis- 
orders of  infants  at  the  breast,  the  proper  consideration  of  which  re- 
quires a  large  amount  of  space,  and  I,  therefore,  refrain  from  making 
any  further  remarks  on  the  subject. 

[As  a  general  rule,  children  in  this  country  are  better  kept  exclu- 
sively on  a  milk  diet  for  at  least  10  months,  especially  if  it  is  in  the 
summer  season.  The  best  addition  then,  is  exsiccated  wheat  flour 
prepared  by  the  process  of  Hards,  and  known  as  Hards'  farinaceous 
food,  prepared  wheat,  imperial  granum,  etc.  Ohio  groats  made  of 
the  oat  kernel,  and  prepared  barley  flour,  are  sometimes  useful  where 
the  habit  of  the  child  is  constipated. — ED.] 


550  THE    PUERPERAL    STATE. 


CHAPTER  III. 

PUERPERAL  ECLAMPSIA. 

BY  the  term  puerperal  eclampsia  is  meant  a  peculiar  kind  of  epi- 
leptiform  convulsions,  which  may  occur  in  the  latter  months  of  preg- 
nancy, or  during,  or  after  parturition,  and  it  constitutes  one  of  the 
most  formidable  diseases  with  which  the  obstetrician  has  to  cope. 
The  attack  is  often  so  sudden  and  unexpected,  so  terrible  in  its 
nature,  and  attended  with  such  serious  danger  both  to  the  mother 
and  child,  that  the  disease  has  attracted  much  attention. 

Its  Doubtful  Etioloyy. — The  researches  of  Lever,  Braun,  Frerichs, 
and  many  other  writers  who  have  shown  the  frequent  association  of 
eclampsia  with  albuminuria,  have,  of  late  years,  been  supposed  to 
clear  up  to  a  great  extent  the  etiology  of  the  disease,  and  to  prove 
its  dependence  on  the  retention  of  urinary  elements  in  the  blood. 
While  the  urinary  origin  of  eclampsia  has  been  pretty  generally 
accepted,  more  recent  observations  have  tended  to  throw  doubt  on 
its  essential  dependence  on  this  cause;  so  that  it  can  hardly  be  said 
that  we  are  yet  in  a  position  to  explain  its  true  pathology  with  cer- 
tainty. These  points  will  require  separate  discussion,  but  it  is  first 
necessary  to  describe  the  character  and  history  of  the  attack. 

Considerable  confusion  exists  in  the  description  of  puerperal  con- 
vulsions from  the  confounding  of  several  essentially  distinct  diseases 
under  the  same  name.  Thus,  in  most  obstetric  works,  it  has  been 
customary  to  describe  three  distinct  classes  of  convulsion ;  the  epi- 
leptic, the  hysterical,  and  the  apoplectic.  The  two  latter,  however, 
come  under  a  totally  different  category.  A  pregnant  woman  may 
suffer  from  hysterical  paroxysms,  or  she  may  be  attacked  with  apo- 
plexy, accompanied  with  coma,  and  followed  by  paralysis.  But  these 
conditions  in  the  pregnant  or  parturient  woman  are  identical  with 
the  same  diseases  in  the  non-pregnant,  and  are  in  no  way  special  in 
their  nature.  True  eclampsia,  however,  is  different  in  its  clinical 
history  from  epilepsy;  although  the  paroxysms,  while  they  last,  are 
essentially  the  same  as  those  of  an  ordinary  epileptic  fit. 

Premonitory  Symptoms. — An  attack  of  eclampsia  seldom  occurs 
without  having  been  preceded  by  certain  more  or  less  well-marked 
precursory  symptoms.  It  is  true  that,  in  a  considerable  number  of 
cases,  these  are  so  slight  as  not  to  attract  attention,  and  suspicion  is 
not  aroused  until  the  patient  is  seized  with  convulsions.  Still,  sub-- 
sequent investigations  will  very  generally  show  that  some  symptoms 
did  exist,  which,  if  observed  and  properly  interpreted,  might  have 
put  the  practitioner  on  his  guard,  and  possibly  enabled  him  to  ward 
off  the  attack.  Hence  a  knowledge  of  them  is  of  real  practical  value. 
The  most  common  are  associated  with  the  cerebrum,  such  as  severe 


PUERPERAL    ECLAMPSIA.  551 

headache,  which  is  the  one  most  generally  observed,  and  is  sometimes 
limited  to  one  side  of  the  head.  Transient  attacks  of  dizziness,  spots 
before  the  eyes,  loss  of  sight,  or  impairment  of  the  intellectual  facul- 
ties, are  also  not  uncommon.  These  signs  in  a  pregnant  woman  are 
of  the  gravest  import,  and  should  at  once  call  for  investigation  into 
the  nature  of  the  case.  Less  marked  indications  sometimes  exist  in 
the  form  of  irritability,  slight  headache  or  stupor,  and  a  general  feel- 
ing of  indisposition.  Another  important  premonitory  sign  is  oedema 
of  the  subcutaneous  cellular  tissue,  especially  of  the  face  or  upper 
extremities,  which  should  at  once  lead  to  an  examination  of  the 
urine. 

Symptoms  of  the  Attack. — "Whether  such  indications  have  preceded 
an  attack  or  not,  as  soon  as  the  convulsion  comes  on  there  can  no 
longer  be  any  doubt  as  to  the  nature  of  the  case.  The  attack  is  gene- 
rally sudden  in  its  onset,  and  in  its  character  is  precisely  that  of  a 
severe  epileptic  fit,  or  of  the  convulsions  in  children.  Close  observa- 
tion shows  that  there  is  at  first  a  short  period  of  tonic  spasm,  affecting 
the  entire  muscular  system.  This  is  almost  immediately  succeeded 
by  violent  clonic  contractions,  generally  commencing  in  the  muscles 
of  the  face,  which  twitch  violently;  the  expression  is  horribly  altered; 
the  globes  of  the  eyes  are  turned  up  under  the  eyelids,  so  as  to  leave 
only  the  white  sclerotics  visible,  and  the  angles  of  the  mouth  are 
retracted  and  fixed  in  a  convulsive  grin.  The  tongue  is  at  the 
same  time  protruded  forcibly,  and,  if  care  be  not  taken,  is  apt  to  be 
lacerated  by  the  violent  grinding  of  the  teeth.  The  face,  at  first  pale, 
soon  becomes  livid  and  cyanosed,  while  the  veins  of  the  neck  are 
distended,  and  the  carotids  beat  vigorously.  Frothy  saliva  collects 
about  the  mouth,  and  the  whole  appearance  is  so  changed  as  to  render 
the  patient  quite  unrecognizable.  The  convulsive  movements  soon 
attack  the  muscles  of  the  body.  The  hands  and  arms,  at  first  rigidly 
fixed,  with  the  thumbs  clenched  into  the  palms,  begin  to  jerk,  and 
the  whole  muscular  system  is  thrown  into  rapidly-recurring  convul- 
sive spasms.  It  is  evident  that  the  involuntary  muscles  are  impli- 
cated in  the  convulsive  action,  as  well  as  the  voluntary.  This  is 
shown  by  a  temporary  arrest  of  respiration  at  the  commencement  of 
the  attack,  followed  by  irregular  and  hurried  respiratory  movements, 
producing  a  peculiar  hissing  sound.  The  occasional  involuntary  ex- 
pulsion of  urine  and  feces  indicates  the  same  fact.  During  the  attack 
the  patient  is  absolutely  unconscious,  sensibility  is  totally  suspended, 
and  she  has  afterwards  no  recollection  of  what  has  taken  place.  For- 
tunately the  convulsion  is  not  of  long  duration,  and,  at  the  outside, 
does  not  last  more  than  three  or  four  minutes,  generally  not  so  long. 
In  most  cases,  after  an  interval,  there  is  a  recurrence  of  the  convul- 
sion, characterized  by  the  same  phenomena,  and  the  paroxysms  are 
repeated  with  more  or  less  force  and  frequency  according  to  the 
severity  of  the  attack.  Sometimes  several  hours  may  elapse  before 
a  second  convulsion  comes  on;  at  others  the  attacks  may  recur  very 
often,  with  only  a  few  minutes  between  them.  In  the  slighter  forms 
of  eclampsia  there  may  not  be  more  than  2  or  3  paroxysms  in.  all; 
in  the  more  serious  as  many  as  50  or  60  have  been  recorded. 

COLLlEGl  Ul=ATU 

l-l-i  \  SMC  lAKs         t  a  KG:  IE  I1  K 


552  THE    PUERPERAL    STATE. 

Condition  between  the  Attacks. — After  the  first  attack  the  patient 
generally  soon  recovers  her  consciousness,  being  somewhat  dazed  and 
somnolent,  with  no  clear  perception  of  what  has  occurred.  If  the 
paroxysms  be  frequently  repeated,  more  or  less  profound  coma  con- 
tinues in  the  intervals  between  them,  which,  no  doubt,  depends  upon 
intense  cerebral  congestion,  resulting  from  the  interference  with  the 
circulation  in  the  great  veins  of  the  neck,  produced  by  spasmodic 
contraction  of  the  muscles.  The  coma  is  rarely  complete,  the  patient 
showing  signs  of  sensibility  when  irritated,  and  groaning  during  the 
uterine  contractions.  In  the  worst  class  of  cases,  the  torpor  may 
become  intense  and  continuous,  and  in  this  state  the  patient  may 
die.  When  the  convulsions  have  entirely  stopped,  and  the  patient 
has  completely  regained  her  consciousness,  and  is  apparently  conva- 
lescent, recollection  of  what  has  taken  place  during,  and  some  time 
before,  the  attack,  may  be  entirely  lost,  and  this  condition  may  last 
for  a  considerable  time.  A  curious  instance  of  this  once  came  under 
my  notice  in  a  lady  who  had  lost  a  brother,  to  whom  she  was  greatly 
attached,  in  the  week  immediately  preceding  her  confinement,  and 
in  whom  the  mental  distress  seemed  to  have  had  a  good  deal  to  do 
in  determining  the  attack.  It  was  many  weeks  before  she  recovered 
her  memory,  and  during  that  time  she  recollected  nothing  about  the 
circumstances  connected  with  her  brother's  death,  the  whole  of  that 
week  being,  as  it  were,  blotted  out  of  her  recollection. 

Relation  of  the  Attacks  to  Labor. — If  the  convulsions  come  on  during 
pregnancy,  we  may  look  upon  the  advent  of  labor  as  almost  a 
certainty ;  and  if  we  consider  the  severe  nervous  shock  and  general 
disturbance,  this  is  the  result  we  might  reasonably  anticipate.  If 
they  occur,  as  is  not  uncommon,  for  the  first  time  during  labor,  the 
pains  generally  continue  with  increased  force  and  frequency,  since 
the  uterus  partakes  of  the  convulsive  action.  It  has  not  rarely 
happened  that  the  pains  have  gone  on  with  such  intensity  that  the 
child  has  been  born  quite  unexpectedly,  the  attention  of  the  practi- 
tioner being  taken  up  with  the  patient.  In  many  cases  the  advent 
of  fresh  paroxysms  is  associated  with  the  commencement  of  a  pain, 
the  irritation  of  which  seems  sufficient  to  bring  on  the  convulsion. 

Results  to  the  Mother  and  Child. — The  results  of  eclampsia  vary 
according  to  the  severity  of  the  paroxysms.  It  is  generally  said  that 
about  1  in  3  or  4  cases  dies.  The  mortality  has  certainly  lessened  of 
late  years,  probably  in  consequence  of  improved  knowledge  of  the 
nature  of  the  disease,  and  more  rational  modes  of  treatment.  This 
is  well  shown  by  Barker,1  who  found  in  1855  a  mortality  of  32  per 
cent,  in  cases  occurring  before  and  during  labor,  and  22  per  cent,  in 
those  after  labor ;  while  since  that  date  the  mortality  has  fallen  to 
14  per  cent.  The  same  conclusion  is  arrived  at  by  Dr.  Phillips,2 
who  has  shown  that  the  mortality  has  greatly  lessened  since  the 
practice  of  repeated  and  indiscriminate  bleeding,  long  considered  the 
sheet  anchor  in  the  disease,  has  been  discontinued,  and  the  adminis- 
tration of  chloroform  substituted. 

1  The  Puerperal  Disease,  p.  125.  2  Guy's  Hosp.  Reps.,  1870. 

. 

'^  '!  H  * 


PUERPERAL    ECLAMPSIA.  553 

Cause  of  Death. — Death  may  occur  during  the  paroxysm,  and  then 
it  may  be  due  to  the  long  continuance  of  the  tonic  spasm  producing 
asphyxia.  It  is  certain  that,  as  long  as  the  tonic  spasm  lasts,  the 
respiration  is  suspended,  just  as  in  the  convulsive  disease  of  children 
known  as  laryngismus  stridulus;  and  it  is  possible  also  that  the  heart 
may  share  in  the  convulsive  contraction  which  is  known  to  affect 
other  involuntary  muscles.  More  frequently,  death  happens  at  a 
later  period,  from  the  combined  effects  of  exhaustion  and  asphyxia. 
The  records  of  post-mortem  examinations  are  not  numerous;  in  those 
we  possess  the  principal  changes  have  been  an  anaemic  condition  of 
the  brain,  with  some  oedematous  infiltration.  In  a  feAV  rare  cases 
the  convulsions  have  resulted  in  effusion  of  blood  into  the  ventricles, 
or  on  the  base  of  the  brain.  The  prognosis  as  regards  the  child  is 
also  serious.  Out  of  36  children,  Hall  Davis  found  26  born  alive, 
10  being  still-born.  There  is  good  reason  to  believe  that  the  con- 
vulsion may  attack  the  child  in  utero ;  of  this  several  examples  are 
mentioned  by  Cazeaux;  or  it  may  be  subsequently  attacked  with 
convulsions,  even  when  apparently  healthy  at  birth. 

Pathology  of  the  Disease. — The  precise  pathology  of  eclampsia 
cannot  be  considered  by  any  means  satisfactorily  settled.  When,  in 
the  year  1843,  Lever  first  showed  that  the  urine  in  patients  suffering 
from  puerperal  convulsions  was  generally  highly  charged  with  albu- 
men— a  fact  which  subsequent  experience  has  amply  confirmed — it 
was  thought  that  a  key  to  the  etiology  of  the  disease  had  been  found. 
It  was  known  that  chronic  forms  of  Blight's  disease  were  frequently 
associated  with  retention  of  urinary  elements  in  the  blood,  and  not 
rarely  accompanied  by  convulsions.  The  natural  inference  was 
drawn,  that  the  convulsions  of  eclampsia  were  also  due  to  toxaemia 
resulting  from  the  retention  of  urea  in  the  blood,  just  as  in  the 
uraemia  of  chronic  Bri grit's  disease;  and  this  view  was  adopted  and 
supported  by  the  authority  of  Braun,  Frerichs,  and  many  other 
writers  of  eminence,  and  was  pretty  generally  received  as  a  satisfac- 
tory explanation  of  the  facts.  Frerichs  modified  it  so  far,  that  he 
held  that  the  true  toxic  element  was  not  urea  as  such,  but  carbonate 
of  ammonia,  resulting  from  its  decomposition;  and  experiments  were 
made  to  prove  that  the  injection  of  this  substance  into  the  veins  of 
the  lower  animals  produced  convulsions  of  precisely  the  same  cha- 
racter as  eclampsia.  Dr.  Hammond,1  of  Maryland,  subsequently 
made  a  series  of  counter  experiments,  which  were  held  as  proving 
that  there  was  no  reason  to  believe  that  urea  ever  did  become  de- 
composed in  the  blood  in  the  way  that  Frerichs  supposed,  or  that 
the  symptoms  of  uraemia  were  ever  produced  in  this  way.  Spiegel- 
berg2  has,  more  recently,  again  examined  the  question  both  clinically, 
in  a  patient  suffering  from  convulsions,  in  whose  blood  an  excess  of 
ammonia  and  urea  was  found,  and  by  experiments  on  dogs,  and 
maintains  the  accuracy  of  Frerichs's  views.  Others  have  believed 
that  the  poisonous  elements  retained  in  the  blood  are  not  urea  or 
the  products  of  its  decomposition,  but  other  extractive  matters  which 

1   Amer.  Journ.,  1861.  2  Arch.  f.  Gyn.,  1870. 

36 


554  THE    PUERPE11AL    STATE. 

have  escaped  detection.  As  time  elapsed,  evidence  accumulated  to 
show  that  the  relation  between  alburninuria  and  eclampsia  was  not 
so  universal  as  was  supposed,  or  at  least  that  some  other  factors 
were  necessary  to  explain  many  of  the  cases.  Numerous  cases  were 
observed  in  which  albumen  was  detected  in  large  quantities,  without 
any  convulsion  following,  and  that,  not  only  in  women  who  had  been 
the  subject  of  Bright's  disease  before  conception,  but  also  when  the 
albuminuria  was  known  to  have  developed  during  pregnancy.  Thus 
Imbert  Goubeyre  found  that  out  of  164  cases  of  the  latter  kind,  95 
had  no  eclampsia;  and  Blot,  out  of  41  cases,  found  that  34  were 
delivered  without  untoward  symptoms.  It  may  be  taken  as  proved, 
therefore,  that  albuminuria  is  by  no  means  necessarily  accompanied 
by  eclampsia.  Cases  were  also  observed  in  which  the  albumen  only 
appeared  after  the  convulsion ;  and  in  these  it  was  evident  that  the 
retention  of  urinary  elements  could  not  have  been  the  cause  of  the 
attack ;  and  it  is  highly  probable  that  in  them  the  albuminuria  was 
produced  by  the  same  cause  which  induced  the  convulsion.  Special 
attention  has  been  called  to  this  class  of  cases  by  Braxton  Hicks,1 
who  has  recorded  a  considerable  number  of  them.  He  says  that  the 
nearly  simultaneous  appearance  of  albuminuria  and  convulsion — and 
it  is  admitted  that  the  two  are  almost  invariably  combined — must 
then  be  explained  in  one  of  three  ways. 

1st.  That  the  convulsions  are  the  cause  of  the  nephritis. 
.  2dly.  That  the  convulsions  and  the  nephritis'  are  produced]  by  the 
same  cause,  e.  #.,  some  detrimental  ingredient  circulating  in  the  blood, 
irritating  both  the  eerebro-spinal  system  and  other  organs  at  the 
same  time. 

3dly.  That  the  highly  congested  state  of  the  venous  system,  in- 
duced by  the  spasm  of  the  glottis  in  eclampsia,  is  able  to  produce  the 
kidney  complication. 

Theory  of  Traube  and  Rosenstein. — More  recently  Traube  and  Ro- 
senstein  have  advanced  a  theory  of  eclampsia,  purporting  to  explain 
these  anomalies.  They  refer  the  occurrence  of  eclampsia  to  acute 
cerebral  ansemia,  resulting  from  changes  in  the  blood  incident  to  preg- 
nancy. The  primary  factor  is  the  hydrasmic  condition  of  the  blood, 
which  is  an  ordinary  concomitant  of  the  pregnant  state,  and,  of  course 
when  there  is  also  albuminuria,  the  watery  condition  of  the  blood  is 
greatly  intensified;  hence  the  frequent  association  of  the  two  states. 
Accompanying  this  condition  of  the  blood,  there  is  increased  tension 
of  the  arterial  system,  which  is  favored  by  the  hypertrophy  of  the 
heart  which  is  known  to  be  a  normal  occurrence  in  pregnancy.  The 
result  of  these  combined  states  is  a  temporary  hypenemia  of  the  brain, 
which  is  rapidly  succeeded  by  serous  effusion  into  the  cerebral  tissues, 
resulting  in  pressure  on  its  minute  vessels,  and  consequent  ancemia. 
There  is  much  in  this  theory  that  accords  with  the  most  recent  views 
as  to  the  etiology  of  convulsive  disease ;  as,  for  example,  the  re- 
searches of  Kussmaul  and  Tenner,  who  have  experimentally  proved 
the  dependence  of  convulsion  on  cerebral  anosmia,  and  of  Brown- 

1  Obstet.  Trans.,  vol.  viii. 


PUERPERAL    ECLAMPSIA.  555 

Sequard,  who  showed  that  an  aajmic  condition  of  the  nerve-centres 
preceded  an  epileptic  attack.  It  explains  also  very  satisfactorily  how 
the  occurrence  of  labor  should  intensify  the  convulsions,  since,  during 
the  acme  of  the  pains,  the  tension  of  the  cerebral  arterial  system  is 
necessarily  greatly  increased.  There  are,  however,  obvious  difficul- 
ties against  its  general  acceptance.  For  example,  it  does  not  satis- 
factorily account  for  those  cases  which  are  preceded  by  well-marked 
precursory  symptoms,  and  in  which  an  abundance  of  albumen  is 
present  in  the  urine.  Here  the  premonitory  signs  are  precisely  those 
which  precede  the  development  of  uraemia  in  chronic  Bright's  disease, 
the  dependence  of  which  on  the  retention  in  the  blood  of  urinary 
elements  can  hardly  be  doubted. 

Excitability  of  Nervous  System. — The  key  to  the  liability  of  the 
puerperal  woman  to  convulsive  attacks  is,  no  doubt,  to  be  found  in 
the  peculiar  excitable  condition  of  the  nervous  system  in  pregnancy 
— a  fact  which  was  clearly  pointed  out  by  the  late  Dr.  Tyler  Smith, 
and  by  many  other  writers.  Her  nervous  system  is,  in  this  respect, 
not  unlike  that  of  children,  in  whom  the  predominant  influence  and 
great  excitability  of  the  nervous  system  are  well-established  facts,  and 
in  whom  precisely  similar  convulsive  seizures  are  of  common  occur- 
rence on  the  application  of  a  sufficiently  exciting  cause. 

Exciting  Causes. — Admitting  this,  we  require  some  cause  to  set 
the.  predisposed  nervous  system  into  morbid  action ;  and  this  we  may 
have  either  in  a  toxaemic,  or  in  an  extremely  watery,  condition  of 
the  blood,  associated  with  albuminuria ;  or  along  with  these,  or  some- 
times independently  of  them,  in  some  excitement,  such  as  strong  emo- 
tional disturbance.  It  is  highly  probable,  however,  that  the  theory 
of  Traube  affords  a  true  insight  into  the  actual  condition  of  the  nerve- 
centres — a  fact  of  much  practical  importance  in  reference  to  treat- 
ment. 

Treatment. — The  management  of  cases  in  which  the  occurrence  of 
suspicious  symptoms  has  led  to  the  detection  of  albuminuria,  has  al- 
ready been  fully  discussed  (p.  194.)  We  shall,  therefore,  here  only 
consider  the  treatment  of  cases  in  which  convulsions  have  actually 
occurred. 

Venesection. — Until  quite  recently  venesection  was  regarded  as  the 
sheet  anchor  in  the  treatment,  and  blood  was  always  removed  copi- 
ously, and,  there  is  sufficient  reason  to  believe,  with  occasional  re- 
markable benefit.  Many  cases  are  recorded  in  which  a  patient,  in 
apparently  profound  coma,  rapidly  regained  her  consciousness  when 
blood  was  extracted  in  sufficient  quantity.  The  improvement,  how- 
ever, was  often  transient,  the  convulsions  subsequently  recurring  with 
increased  vigor.  There  are  good  theoretical  grounds  for  believing 
that  blood-letting  can  only  be  of  merely  temporary  use,  and  may 
even  increase  the  tendency  to  convulsion.  These  are  so  well  put  by 
Schroeder,  that  I  cannot  do  better  than  quote  his  observations  on 
this  point: — "If,"  he  says,  "the  theory  of  Traube  and  Eosenstein  be 
correct,  a  ^udden  depletion  of  the  vascular  system,  by  which  the 
pressure  is  diminished,  must  stop  the  attacks.  From  experience  it  is 
known  that  after  venesection  the  quantity  of  blood  soon  becomes  the 


556  THE    PUERPERAL    STATE. 

same  through  the  serum  taken  from  all  the  tissues,  while  the  quality 
is  greatly  deteriorated  by  the  abstraction  of  blood.  A  short  time 
after  venesection  we  shall  expect  to  find  the  former  blood-pressure 
in  the  arterial  system,  but  the  blood  far  more  watery  than  previously. 
From  this  theoretical  consideration  it  follows  that  abstraction  of 
blood,  if  the  above-mentioned  conditions  really  cause  convulsions, 
must  be  attended  by  an  immediate  favorable  result,  and,  under  cer- 
tain circumstances,  the  whole  disease  may  surely  be  cut  short  by  it. 
But,  if  all  other  conditions  remain  the  same,  the  blood-pressure  will 
after  some  time  again  reach  its  former  height.  The  quantity  of  blood 
has,  in  the  mean  time,  been  greatly  deteriorated,  and  consequently 
the  danger  of  the  disease  will  be  increased." 

In  Properly-selected  Cases  Venesection  is  a  Valuable  Remedy. — These 
views  sufficiently  well  explain  the  varying  opinions  held  with  regard 
to  this  remedy,  and  enable  us  to  understand  why,  while  the  effects 
of  venesection  have  been  so  lauded  by  certain  authors,  the  mortality 
has  admittedly  been  much  lessened  since  its  indiscriminate  use  has 
been  abandoned.  It  does  not  follow  because  a  remedy,  when  carried 
to  excess,  is  apt  to  be  hurtful,  that  it  should  be  discarded  altogether; 
and  I  have  no  doubt  that,  in  properly-selected  cases,  and  judiciously 
employed,  venesection  is  a  valuable  aid  in  the  treatment  of  eclampsia, 
and  that  it  is  specially  likely  to  be  useful  in  mitigating  the  first 
violence  of  the  attack,  and  in  giving  time  for  other  remedies  to  come 
into  action.  Care  should,  however,  be  taken  to  select  the  cases 
properly,  and  it  will  be  specially  indicated  when  there  is  marked 
evidence  of  great  cerebral  congestion  and  vascular  tension,  such  as 
a  livid  face,  a  full  bounding  pulse,  and  strong  pulsation  in  the  caro- 
tids. The  general  constitution  of  the  patient  may  also  serve  as  a 
guide  in  determining  its  use,  and  we  shall  be  the  more  disposed  to 
resort  to  it  if  the  patient  be  a  strong  and  healthy  woman ;  while,  on 
the  other  hand,  if  she  be  feeble  and  weak,  we  may  wisely  discard  it, 
and  trust  entirely  to  other  means.  In  any  case,  it  must  be  looked 
upon  as  a  temporary  expedient  only;  useful  in  warding  off  immediate 
danger  to  the  cerebral  tissues,  but  never  as  the  main  agent  in  treat- 
ment. Nor  can  it  be  permissible  to  bleed  in  the  heroic  manner  fre- 
quently recommended.  A  single  bleeding,  the  amount  regulated  by 
the  effect  produced,  is  all  that  is  ever  likely  to  be  of  service. 

Compression  of  the  Carotids. — As  a  temporary  expedient,  having 
the  same  object  in  view,  compression  of  the  carotids  during  the  par- 
oxysms is  worthy  of  trial.  This  was  proposed  by  Trousseau  in  the 
eclampsia  of  infants,  but  I  am  not  aware  that  it  has  been  tried  in 
puerperal  convulsions.  It  is  a  simple  measure,  and  it  offers  the  ad- 
vantage of  not  leading  to  any  permanent  deterioration  of  the  blood, 
as  in  venesection. 

Administration  of  Purgatives. — As  a  subsidiary  means  of  diminish- 
ing vascular  tension  the  administration  of  a  strong  purgative  is  de- 
sirable, and  has  the  further  effect  of  removing  any  irritant  matter 
that  may  be  lodged  in  the  intestinal  tract.  If  the  patient  be  con- 
scious a  full  dose  of  the  compound  jalap  powder  may  be  given,  or  a 


PUERPERAL    ECLAMPSIA.  557 

few  grains  of  calomel  combined  with  jalap;  and  if  she  be  comatose, 
and  unable  to  swallow,  a  drop  of  croton  oil,  or  a  quarter  of  a  grain 
of  elaterium,  may  be  placed  on  the  back  of  the  tongue. 

Administration  of  Sedatives  and  Narcotics. — The  great  indication 
in  the  management  of  eclampsia  is  the  controlling  of  convulsive  action 
by  means  of  sedatives.  Foremost  amongst  them  must  be  placed  the 
inhalation  of  chloroform,  a  remedy  which  is  frequently  remarkably 
iiseful,  and  which  has  the  advantage  of  being  applicable  at  all  stages 
of  the  disease,  and  whether  the  patient  be  comatose  or  not.  Theo- 
retical objections  have  been  raised  against  its  employment,  as  being 
likely  to  increase  cerebral  congestion;  of  this  there  is  no  satisfactory 
proof;  on  the  contrary,  there  is  reason  to  think  that  chloroform 
inhalation  has  rather  the  effect  of  lessening  arterial  tension,  while 
it  certainly  controls  the  violent  muscular  action  by  which  the  hyper- 
aemia  is  so  much  increased.  Practically  no  one  who  has  used  it  can 
doubt  its  great  value  in  diminishing  the  force  and  frequency  of  the 
convulsive  paroxysms.  Statistically  its  usefulness  is  shown  by  Char- 
pentier,  in  his  thesis  on  the  effects  of  various  methods  of  treatment 
in  eclampsia,  since  out  of  63  cases  in  which  it  was  used,  in  48  it  had 
the  effect  of  diminishing  or  arresting  the  attacks,  1  only  proving 
fatal.  The  mode  of  administration  has  varied.  Some  have  given 
it  almost  continuously,  keeping  the  patient  in  a  more  or  less  profound 
state  of  anesthesia.  Others  have  contented  themselves  with  care- 
fully watching  the  patient,  and  exhibiting  the  chloroform  as  soon  as 
there  were  any  indications  of  a-  recurring  paroxysm,  with  the  view 
of  controlling  its  intensity.  The  latter  is  the  plan  I  have  myself 
adopted,  and  of  the  value  of  which,  in  most  cases,  I  have  no  doubt. 
Every  now  and  again,  cases  will  occur  in  which  chloroform  inhala- 
tion is  insufficient  to  control  the  paroxysm,  or  in  which,  from  the 
very  cyanosed  state  of  the  patient,  its  administration  seems  contra- 
indicated.  Moreover,  it  is  advisable  to  have,  if  possible,  some  remedy 
more  continuous  in  its  action,  and  requiring  less  constant  personal 
supervision.  Latterly  the  internal  administration  of  chloral  has  been 
recommended  for  this  purpose.  My  own  experience  is  decidedly  in 
its  favor,  and  I  have  used,  as'  I  believe,  with  marked  advantage  a 
combination  of  chloral  with  bromide  of  potassium,  in  the  proportion 
of  twenty  grains  of  the  former  to  half  a  drachm  of  the  latter,  repeated 
at  intervals  of  from  four  to  six  hours.1  If  the  patient  be  unable  to 
swallow,  the  chloral  may  be  given  in  an  enema.  The  remarkable 
influence  of  bromide  of  potassium  in  controlling  the  eclampsia  of 
infants  would  seem  to  be  an  indication  for  its  use  in  puerperal  cases. 
Fordyce  Barker  is  opposed  to  the  use  of  chloral,  which  he  thinks 
excites  instead  of  lessening  reflex  irritability.2  Another  remedy, 
not  entirely  free  from  theoretical  objections,  but  strongly  recom- 
mended, is  the  subcutaneous  injection  of  morphia,  which  has  the 

['  We  have  used  bromide  of  sodium  and  chloral  with  good  effect ;  but  as  the  latter 
is  an  intoxicant,  have  used  doses  of  10  to  15  grains,  and  at  shorter  intervals. — ED.] 
2  The  Puerperal  Diseases,  p.  120. 


558  THE    PUERPERAL    STATE. 

advantage  of  being  applicable  when  the  patient  is  quite  unable  to 
swallow.  It  maybe  given  in  doses  of  one-third  of  a  grain,  repeated 
in  a  few  hours,  so  as  to  keep  the  patient  well  under  its  influence.  It 
is  to  be  remembered  that  the  object  is  to  control  muscular  action,  so 
as  to  prevent,  as  much  as  possible,  the  violent  convulsive  paroxysm, 
and,  therefore,  it  is  necessary  that  the  narcosis,  however  produced, 
should  be  continuous.  It  is  rational,  therefore,  to  combine  the  inter- 
mittent action  of  chloroform  with  the  more  continuous  action  of  other 
remedies,  so  that  the  former  should  supplement  the  latter  when  in- 
sufficient. 

Other  remedies,  supposed  to  act  in  the  way  of  antidotes  to  uramiic 
poisoning,  have  been  advised,  such  as  acetic  or  benzoic  acid,  but 
they  are  far  too  uncertain  to  have  any  reliance  placed  on  them,  and 
they  distract  attention  from  more  useful  measures. 

Precautions  during  the  Paroxysm.  —  Precautions  are  necessary 
during  the  fits  to  prevent  the  patient  injuring  herself,  especially  to 
obviate  laceration  of  the  tongue ;  the  latter  can  be  best  done  by 
placing  something  between  the  teeth  as  the  paroxysm  comes  on,  such 
as  the  handle  of  a  teaspoon  enveloped  in  several  folds  of  flannel. 

Obstetric  Management. — The  obstetric  management  of  eclampsia 
will  naturally  give  rise  to  much  anxiety,  and  on  this  point  there  has 
been  considerable  difference  of  opinion.  On  the  one  hand,  we  have 
practitioners  who  advise  the  immediate  emptying  of  the  uterus,  even 
when  labor  has  commenced;  on  the  other,  those  who  would  leave 
the  labor  entirely  alone.  Thus  Gooch  said,  "  attend  to  the  convul- 
sions, and  leave  the  labor  to  take  care  of  itself;"  andSchroeder  says, 
"especially  no  kind  of  obstetric  manipulation  is  required  for  the 
safety  of  the  mother,"  but  he  admits,  however,  that  it  is  sometimes 
advisable  to  hasten  the  labor  to  insure  the  safety  of  the  child. 

In  cases  in  which  the  convulsions  come  on  during  labor,  the  pains 
are  often  strong  and  regular,  the  labor  progresses  satisfactorily,  and 
no  interference  is  needful.  In  others  we  cannot  but  feel  that  empty- 
ing the  uterus  would  be  decidedly  beneficial.  We  have  to  reflect, 
however,  that  any  active  interference  might,  of  itself,  prove  very  irri- 
tating, and  excite  fresh  attacks.  The  influence  of  uterine  irritation 
is  apparent,  by  the  frequency  with  which  the  paroxysms  recur  with 
the  pains.  If,  therefore,  the  os  be  undilated,  and  labor  have  not 
begun,  no  active  means  to  induce  it  should  be  adopted,  although  the 
membranes  may  be  ruptured  with  advantage,  since  that  procedure 
tends  to  no  irritation.  Forcible  dilatation  of  the  os,  and  ^specially 
turning  are  strongly  contra-indicated. 

The  rule  laid  down  by  Tyler  Smith  seems  that  which  is  most  ad- 
visable to  follow — that  we  should  adopt  the  course  which  seems  least 
likely  to  prove  a  souce  of  irritation  to  the  mother.  Thus  if  the  fits 
seems  evidently  induced  and  kept  up  by  the  pressure  of  the  foetus, 
and  the  head  be  within  reach,  the  forceps  or  even  craniotomy  may 
be  resorted  to.  But  if,  on  the  other  hand,  there  be  reason  to  think 
that  the  operation  necessary  to  complete  delivery  is  likely  per  se  to 
prove  a  greater  source  of  irritation  than  leaving  the  case  to  nature, 
then  we  should  not  interfere. 


PUERPERAL  INSANITY.  559 

[In  one  case  of  eclampsia  in  a  primipara,  the  attacks  \verc  inter- 
mittent and  lasted  during  the  pains.  As  the  labor  progressed,  the 
convulsions  became  more  marked  until  the  head  of  the  foetus  began 
to  dilate  the  vulva,  when  they  diminished  and  finally  ceased.  The 
forceps  we're  ready  for  application,  but  were  not  required. — ED.] 


CHAPTER  IV. 

PUERPERAL   INSANITY. 

Classification. — Under  the  head  of  "Puerperal  Mania"  writers  on 
obstetrics  have  indiscriminately  classed  all  cases  of  mental  disease 
connected  with  pregnancy  and  parturition.  The  result  has  been 
unfortunate,  for  the  distinction  between  the  various  types  of  mental 
disorder  has,  in  consequence,  been  very  generally  lost  sight  of.  But 
little  study  of  the  subject  suffices  to  show  that  the  term  Puerperal 
Mania  is  wrong  in  more  ways  than  one,  for  we  find  that  a  large 
number  of  cases  are  not  cases  of  "  mania"  at  all,  but  of  melancholia; 
while  a  considerable  number  are  not,  strictly  speaking,  "puerperal," 
as  they  either  come  on  during  pregnancy,  or  long  after  the  immediate 
risks  of  the  puerperal  period  are  over,  being  in  the  latter  case  asso- 
ciated with  anaemia  produced  by  over-lactation.  For  the  sake  of 
brevity,  the  generic  term  "Puerperal  Insanity"  may  be  employed  to 
cover  all  cases  of  mental  disorders  connected  with  gestation,  which 
may  be  further  conveniently  subdivided  into  three  classes,  each 
having  its  special  characteristics,  viz. : — 

I.  The  Insanity  of  Pregnancy. 

II.  Puerperal  Insanity,  properly  so  called,  that  is  insanity  coming 
on  within  a  limited  period  after  delivery. 

III.  The  Insanity  of  Lactation. 

This  division  is  a  strictly  natural  one,  and  includes  all  the  cases 
likely  to  come  under  observation.  The  relative  proportion  these 
classes  bear  to  each  other  can  only  be  determined  by  accurate  statis- 
tical observations  on  a  large  scale,  but  these  materials  we  do  not 
possess.  The  returns  from  large  asylums  are  obviously  open  to 
objection,  for  only  the  worst  and  most  confirmed  cases  find  their  way 
into  these  institutions,  while  by  far  the  greater  proportion,  both 
before  and  after  labor,  are  treated  in  their  own  homes. 

Taking  such  returns  as  only  approximative,  we  find  from  Dr. 
Batty  Tuke1  that  in  the  Edinburgh  Asylum  out  of  105  cases  of  puer- 
peral insanity,  28  occurred  before  delivery,  13  during  the  puerperal 

'  Edin.  Med.  Journ.,  vol.  x. 


560  THE    PUERPERAL    STATE. 

period,  and  54  daring  lactation.  The  relative  proportions  of  each 
per  hundred  are  as  follows : — 

Insanity  of  Pregnancy,  8.06  per  cent. 
Puerperal  Insanity,      47.09        " 
Insanity  of  Lactation,  34.  8        " 

Marce*1  collects  together  several  series  of  cases  from  various  authori- 
ties, amounting  to  310  in  all,  and  the  results  are  not  very  different 
from  those  of  the  Edinburgh  Asylum,  except  in  the  relatively  smal- 
ler number  of  cases  occurring  before  delivery.  The  percentage  is 
calculated  from  his  figures — • 

Insanity  of  Pregnancy,  8.06  per  cent. 
Puerperal  Insanity,      58.06        " 
Insanity  of  Lactation,  30.30        " 

As  each  of  these  classes  differs  in  various  important  respects  from 
the  others,  it  will  be  better  to  consider  each  separately. 

Insanity  of  Pregnancy, — The  Insanity  of  Pregnancy  is,  without 
doubt,  the  least  common  of  the  three  forms.  The  intense  mental 
depression  which  in  many  women  accompanies  pregnancy,  and  causes 
the  patient  to  take  a  desponding  view  of  her  condition,  and  to  look 
forward  to  the.  result  of  her  labor  with  the  most  gloomy  apprehen- 
sion, seems  to  be  often  only  a  lesser  degree  of  the  actual  mental 
derangement  which  is  occasionally  met  with.  The  relation  between 
the  two  states  is  further  borne  out  by  the  fact  that  a  large  majority 
of  cases  of  insanity  during  pregnancy  are  well  marked  types  of 
melancholia;  out  of  28  cases,  reported  by  Tuke,  15  were  examples 
of  pure  melancholia,  5  of  dementia  with  melancholia.  In  many  of 
these  the  attack  could  be  traced  as  developing  itself  out  of  the  ordi- 
nary hypochondriasis  of  pregnancy.  In  others  the  symptoms  came 
on  at  a  later  period  of  pregnancy,  the  earlier  months  of  which  had 
not  been  marked  by  any  unusual  lowness  of  spirits.  The  age  of  the 
patient  seems  to  have  some  influence,  the  proportion  of  cases  between 
30  and  40  years  of  age  being  much  larger  than  in  younger  women. 
A  larger  proportion  of  cases  occur  in  primiparae  than  in  multipart, 
a  fact  that,  no  doubt,  depends  on  the  greater  dread  and  apprehension 
experienced  by  women  who  are  pregnant  for  the  first  time,  especially 
if  not  very  young.  Hereditary  disposition  plays  an  important  part, 
as  in  all  forms  of  puerperal  insanity.  It  is  not  always  easy  to  ascer- 
tain the  fact  of  an  hereditary  taint,  since  it  is  often  studiously  con- 
cealed by  the  friends.  Tuke,  however,  found  distinct  evidence  of  it 
in  no  less  than  12  out  of  28  cases.  Fiirstner2  believes  that  other 
neuroses  have  an  important  influence  in  the  causation  of  the  disease. 
Out  of  32  cases  he  found  direct  hereditary  taint  in  9,  but  in  11  more 
there  was  a  family  history  of  epilepsy,  drunkenness,  or  hysteria. 

Period  of  Pregnancy  at  which  it  Occurs. — The  period  of  pregnancy, 
at  which  mental  derangement  most  commonly  shows  itself,  varies. 
Most  generally,  perhaps,  it  is  at  the  end  of  the  third,  or  the  beginning 

1  Trait6  de  la  Folie  des  Femmes  enceintes. 
8  Archiv  fUr  Psychiatric,  Band  v.  Heft  2. 


PUERPERAL    INSANITY. 

of  the  fourth  month.  It  may,  however,  begin  with  conception,  and 
even  return  with  every  impregnation.  Montgomery  relates  an  in- 
stance in  which  it  recurred  in  three  successive  pregnancies.  Marce 
distinguishes  between  true  insanity  coming  on  during  pregnancy, 
and  aggravated  hypochondriasis,  by  the  fact  that  the  latter  usually 
lessens  after  the  third  month,  while  the  former  most  commonly  only 
begins  after  that  date.  It  is  unquestionable  that  in  many  cases  no 
such  distinction  can  be  made,  and  that  the  two  are  often  very  inti- 
mately associated. 

Form  of  Insanity. — The  form  of  insanity  does  not  differ  from  ordi- 
nary melancholia.  The  suicidal  tendency  is  generally  very  strongly 
developed.  Should  the  mental  disorder  continue  after  delivery,  the 
patient  may  very  probably  experience  a  strong  impulse  to  kill  her 
child.  Moral  perversions  have  been  not  uncommonly  observed. 
Tuke  especially  mentions  a  tendency  to  dipsomania  in  the  early 
months,  even  in  women  who  have  not  shown  any  disposition  to 
excess  at  other  times.  He  suggests  that  this  may  be  an  exaggeration 
of  the  depraved  appetite,  or  morbid  craving,  so  commonly  observed 
in  pregnant  women,  just  as  melancholia  may  be  a  further  develop- 
ment of  lowness  of  spirits.  Laycock  mentions  a  disposition  to  "klep- 
tomania" as  very  characteristic  of  the  disease.  Casper1  relates  a 
curious  case  where  this  occurred  in  a  pregnant  lady  of  rank,  and  the 
influence  of  pregnancy,  in  developing  an  irresistible  tendency,  was 
pleaded  in  a  criminal  trial  in  which  one  of  her  petty  thefts  had 
involved  her. 

Prognosis — The  prognosis  may  be  said  to  be,  on  the  whole,  favor- 
able. Out  of  Dr.  Tuke's  28  cases,  19  recovered  within  six  months. 
There  is  little  hope  of  a  cure  until  after  the  termination  of  the  preg- 
nancy, as  out  of  19  cases  recorded  by  Marc£  only  in  2  did  the  insanity 
disappear  before  delivery. 

Transient  Mania  during  Delivery. — There  is  a  peculiar  form  of 
mental  derangement  sometimes  observed  during  labor,  which  is  by 
some  talked  of  as  a  temporary  insanity.  It  may,  perhaps,  be  more 
accurately  described  as  a  kind  of  acute  delirium,  produced,  in  the 
latter  stage  of  labor,  by  the  intensity  of  the  suffering  caused  by  the 
pains.  According  to  Montgomery,  it  is  most  apt  to  occur  as  the  head 
is  passing  through  the  os  uteri,  or,  at  a  later  period,  during  the  ex- 
pulsion of  the  child.  It  may  consist  of  merely  a  loss  of  control  over 
the  mind,  during  which  the  patient,  unless  carefully  watched,  might, 
in  her  agony,  seriously  injure  herself  or  her  child.  Sometimes  it 
produces  actual  hallucination,  as  in  the  case  described  by  Tarnier, 
in  which  the  patient  fancied  she  saw  a  spectre  standing  at  the  foot 
of  her  bed,  which  she  made  violent  efforts  to  drive  away.  This  kind 
of  mania,  if  it  may  be  so  called,  is  merely  transitory  in  its  character, 
and  disappears  as  soon  as  the  labor  is  over.  From  a  medico-legal 
point  of  view  it  may  be  of  importance,  as  it  has  been  held  by  some 
that  in  certain  cases  of  infanticide  the  mother  has  destroyed  the  child 
when  in  this  state  of  transient  frenzy,  and  when  she  was  irrespon- 

1  Casper's  Forensic  Medicine,  vol.  iv. 


562  THE    PUERPERAL    STATE. 

sible  for  her  acts.  In  the  treatment  of  this  variety  of  delirium  we 
must,  of  course,  try  to  lessen  the  intensity  of  the  suffering,  and  it  is 
in  such  cases  that  chloroform  will  find  one  of  its  most  valuable 
applications. 

Puerperal  Insanity  (proper). — True  puerperal  insanity  has  always 
attracted  much  attention  from  obstetricians,  often  to  the  exclusion  of 
other  forms  of  mental  disturbance  connected  with  the  puerperal 
state.  We  may  define  it  to  be,  that  form  of  insanity  which  comes 
on  within  a  limited  period  after  delivery,  and  which  is  probably  in- 
timately connected  with  that  process.  Out  of  73  examples  of  the 
disease  tabulated  by  Dr.  Tuke,  only  2  came  on  later  than  a  month 
after  delivery,  and  in  these  there  were  other  causes  present,  which 
might  possibly  remove  them  from  this  class. 

Although  a  large  number  of  these  cases  assume  the  character  of 
acute  mania,  that  is  by  no  means  the  only  kind  of  insanity  which  is 
observed,  a  not  inconsiderable  number  being  well-marked  examples 
of  melancholia.  The  distinction  between  them  was  long  ago  pointed 
out  by  Gooch,  whose  admirable  monograph  on  the  disease  contains 
one  of  the  most  graphic  and  accurate  accounts  of  puerperal  insanity 
that  has  yet  been  written. 

There  are  also  some  peculiarities  as  to  the  period  at  which  these 
varieties  of  insanity  show  themselves,  which,  taken  in  connection 
with  certain  facts  in  their  etiology,  may  eventually  justify  us  in 
drawing  a  stronger  line  of  demarcation  between  them  than  has  been 
usual.  It  appears  that  cases  of  acute  mania  are  apt  to  come  on  at  a 
period  much  nearer  delivery  than  melancholia.  Thus  Tuke  found 
that  all  the  cases  of  mania  came  on  within  sixteen  days  after  delivery, 
and  that  all  cases  of  melancholia  developed  themselves  after  that 
period.  We  shall  presently  see  that  one  of  the  most  recent  theories 
as  to  the  causation  of  the  disease  attributes  it  to  some  morbid  condi- 
tion of  the  blood.  Should  further  investigation  confirm  this  supposi- 
tion, inasmuch  as  septic  conditions  of  the  blood  are  most  likely  to 
occur  a  short  time  after  labor,  it  would  not  be  an  improbable  hy- 
pothesis that  cases  of  acute  mania,  occurring  within  a  short  time 
after  labor,  may  depend  on  such  septic  causes,  while  melancholia  is 
more  likely  to  arise  from  general  conditions  favoring  the  develop- 
ment of  mental  disease.  This  must,  however,  be  regarded  as  a  mere 
speculation  requiring  further  investigation. 

Causes. — Hereditary  predisposition  is  very  frequently  met  with, 
and  a  careful  inquiry  into  the  patient's  history  will  generally  show 
that  other  members  of  the  family  have  suffered  from  mental  derange- 
ment. Reid  found  that  out  of  111  cases  in  Bethlehem  Hospital  there 
was  clear  evidence  of  hereditary  taint  in  45.  Tuke  made  the  same 
observation  in  22  out  of  his  73  cases ;  and,  indeed,  it  is  pretty  gene- 
rally admitted  by  all  alienist  physicians  that  hereditary  tendencies 
form  one  of  the  strongest  predisposing  causes  of  mental  disturbance 
in  the  puerperal  state.  In  a  large  proportion  of  cases  circumstances 
producing  debility  and  exhaustion,  or  mental  depression,  have  pre- 
ceded the  attack.  Thus  it  is  often  found  that  patients  attacked  with 
it  have  have  had  post-partum  hemorrhage,  or  have  suffered  from 


PUERPERAL  INSANITY.  563 

some  other  conditions  producing  exhaustion,  such  as  severe  and  com- 
plicated labor;  or  they  may  have  been  weakened  by  over-frequent 
pregnancies,  or  by  lactation  during  the  early  months  of  pregnancy. 
Indeed  anaemia  is  always  well  marked  in  this  disease.  Mental  condi- 
tions also  are  frequently  traceable  in  connection  with  its  production. 
Morbid  dread  during  pregnancy,  insufficient  to  produce  insanity  be- 
fore delivery,  may  develop  into  mental  derangement  after  it.  Shame 
and  fear  of  exposure  in  unmarried  women  not  unfrequently  lead  to 
it,  as  is  evidenced  by  the  fact  that  out  of  2281  cases,  gathered  from 
the  reports  of  various  asylums,  above  6-i  per  cent,  were  unmarried.1 
Sudden  moral  shocks  or  vivid  mental  impressions  may  be  the  deter- 
mining cause  in  predisposed  persons.  Gooch  narratives  an  example 
of  this  in  a  lady  who  was  attacked  immediately  after  a  fright  pro- 
duced by  a  fire  close  to  her  house,  the  hallucinations  in  this  case 
being  all  connected  with  light ;  and  T_yler  Smith  that  of  another 
whose  illness  dated  from  the  sudden  death  of  a  relative.  The  age  of 
the  patient  has  some  influence,  and  there  seems  to  be  a  decidedly 
greater  liability  at  advanced  ages,  especially  when  such  women  are 
pregnant  for  the  first  time. 

Theory  of  its  Dependence  on  Morbid  State  of  the  Blood. — The  possi- 
bility of  the  acute  form  of  puerperal  insanity,  coming  on  shortly 
after  delivery,  being  dependent  on  some  form  of  septicaamia  is  one 
which  deserves  careful  consideration.  The  idea  originated  with  Sir 
James  Simpson,  who  found  albumen  in  the  urine  of  4  patients.  He 
suggested  that  this  might  probably  indicate  the  presence  in  the  blood 
of  certain  urinary  constituents,  which  might  have  determined  the 
attack,  much  in  the  same  way  as  in  eclampsia.  Dr.  Donkin  subse- 
quently wrote  an  important  paper,2  in  which  he  warmly  supported 
this  theory,  and  arrived  at  the  conclusion,  "  that  the  accute  danger- 
ous class  of  cases  are  examples  of  urtemic  blood-poisoning,  of  which 
the  mania,  rapid  pulse,  and  other  constitutional  symptoms  are  merely 
the  phenomena ;  and  that  the  affection,  therefore,  ought  to  be  termed 
urasrnic  or  renal  puerperal  mania,  in  contradistiction  to  the  other 
form  of  the  disease."  Pie  also  suggests  that  the  immediate  poison 
may  be  carbonate  of  ammonia,  resulting  from  the  decomposition  of 
urea  retained  in  the  blood.  It  will  be  observed,  therefore,  that  the 
pathological  condition  producing  puerperal  mania  would,  supposing 
this  theory  to  be  correct,  be  precisely  the  same  as  that  which,  at 
other  times,  is  supposed  to  give  rise  to  puerperal  eclampsia.  There 
can  be  no  doubt  that  the  patient,  immediately  after  delivery,  is  in  a 
condition  rendering  her  peculiarly  liable  to  various  forms  of  septic 
disease  ;  and  it  must  be  admitted  that  there  is  no  inherent  improba- 
bility in  the  supposition  that  some  morbid  material  circulating  in  the 
blood  may  be  the  effective  cause  of  the  attack,  in  a  person  otherwise 
predisposed  to  it.  It  is  also  certain,  as  I  have  already  pointed  out, 
that  there  are  two  distinct  classes  of  cases,  differing  according  to  the 
period  after  delivery  at  which  the  attack  comes  on.  Whether  this 
difference  depends  on  the  presence  in  the  blood  of  some  septic  mat- 

1  Journ.  of  Mental  Science,  1870-1,  p.  159.          2  Edin.  Med.  Journ.,  vol.  vii. 


564  THE    PUERPERAL    STATE. 

ter — especially  urinary  excreta — is  a  question  which  our  knowledge 
by  no  means  justifies  us  in  answering  ;  it  is,  however,  one  which  well 
merits  further  careful  study. 

Objections  to  this  Theory. — It  is  only  fair  to  point  to  some  difficul- 
ties which  appear  to  militate  against  the  view  which  Dr.  Donkin 
maintains.  In  the  first  place,  the  albuminuria  is  merely  transient, 
while  its  supposed  effects  last  for  weeks  or  months.  Sir  James 
Simpson  says,  with  regard  to  his  cases  :  "  I  have  seen  all  traces  of 
albuminuria  in  puerperal  insanity  disappear  from  the  urine  within 
fifty  hours  of  the  access  of  the  malady.  The  general  rapidity  of  its 
disappearance  is,  perhaps,  the  principal,  or,  indeed,  the  only  reason 
why  this  complication  has  escaped  the  notice  of  those  physicians 
among  us  who  devote  themselves  with  such  ardor  and  zeal  to  the 
treatment  of  insanity  in  our  public  asylums."  This  apparent  anomaly 
Simpson  attempts  to  explain  by  the  hypothesis  that,  when  once  the 
uraemic  poisoning  has  done  its  work,  and  set  the  disease  in  progress, 
the  mania  progresses  of  itself.  This,  however,  is  pure  speculation ; 
and,  in  the  supposed  analogous  case  of  eclampsia,  the  albuminuria 
certainly  lasts  as  long  as  its  effects.  It  is  not  easy  to  understand, 
also,  why  uraemic  poisoning  should  in  one  case  give  rise  to  insanity, 
and  in  another  to  convulsions.  For  all  we  know  to  the  contrary, 
transient  albuminuria  may  be  much  more  common  after  delivery  than 
has  been  generally  supposed,  and  further  investigation  on  this  point 
is  required.  Albumen  is  by  no  means  unfrequently  observed  in  the 
urine,  for  a  short  time,  in  various  conditions  of  the  body,  without 
any  serious  consequences,  as,  for  example,  after  bathing ;  and  we 
may  too  readily  draw  an  unjustifiable  conclusion  from  its  detection  in 
a  few  cases  of  mania.  There  are,  however,  many  other  kinds  of  blood- 
poisoning,  besides  uraemia,  which  may  have  an  influence  in  the  pro- 
duction of  the  disease,  and  it  is  to  be  hoped  that  future  observations 
may  enable  us  to  speak  with  more  certainty  on  this  point. 

Prognosis. — The  prognosis  of  puerperal  insanity  is  a  point  which 
will  always  deeply  interest  those  who  have  to  deal  with  so  distress- 
ing a  malady.  It  may  resolve  itself  into  a  consideration  of  the  im- 
mediate risk  to  life,  and  of  the  chances  of  ultimate  restoration  of  the 
mental  faculties.  It  is  an  old  aphorism  of  Gooch's,  and  one  the 
correctness  of  which  is  justified  by  modern  experience,  that  "mania 
is  more  dangerous  to  life,  melancholia  to  reason."  It  has  very  gene- 
rally been  supposed  that  the  immediate  risk  to  life  in  puerperal 
mania  is  not  great,  and,  on  the  whole,  this  may  be  taken  as  correct. 
Tuke  found  that  death  took  place,  from  all  causes,  in  10.9  of  the 
cases  under  observation ;  these,  however,  were  all  women  who  had 
been  admitted  into  asylums,  and  in  whom  the  attack  may  be  assumed 
to  have  been  exceptionally  severe.  Great  stress  was  laid  by  Hunter 
and  Gooch  on  extreme  rapidity  of  the  pulse,  as  indicating  a  fatal 
tendency.  There  can  be  no  doubt  that  it  is  a  symptom  of  great 
gravity,  but  by  no  means  one  which  need  lead  us  to  despair  of  our 
patient's  recovery.  The  most  dangerous  class  of  cases  are  those  at- 
tended with  some  inflammatory  complication ;  and  if  there  be  marked 
elevation  of  temperature,  indicating  the  presence  of  some  such  con- 


PUERPERAL  INSANITY.  505 

comitant  state,  our  prognosis  must  be  more  grave  than  when  there 
is  mere  excitement  of  the  circulation. 

Post-mortem  Siyns. — There  are  no  marked  post-mortem  signs 
found  in  fatal  cases  to  guide  us  in  forming  an  opinion  as  to  the  nature 
of  the  disease.  "No  constant  morbid  changes,"  says  Tyler  Smith, 
"  are  found  within  the  head,  and  most  frequently  the  only  condition 
found  in  the  brain  is  that  of  unusual  paleness  and  exsanguinity 
Many  pathologists  have  also  remarked  upon  the  extremely  empty 
condition  of  the  bloodvessels,  particularly  the  veins. 

Duration  of  the  Disease. — The  duration  of  the  disease  varies  con- 
siderably. Generally  speaking,  cases  of  mania  do  not  last  so  long  as 
melancholia,  and  recovery  takes  place  within  a  period  of  three 
months,  often  earlier.  Very  few  of  the  cases  admitted  into  the 
Edinburgh  Asylum  remained  there  more  than  six  months,  and  after 
that  time  the  chances  of  ultimate  recovery  greatly  lessened.  When 
the  patient  gets  well,  it  often  happens  that,  her  recollection  of  the 
events  occurring  during  her  illness  is  lost ;  at  other  times,  the  delu- 
sions from  which  she  suffered  remain,  as,  for  example,  in  a  case 
which  was  under  my  care,  in  which  the  personal  antipathies  which 
the  patient  formed  when  insane  became  permanently  established. 

Insanity  of  Lactation. — 54  out  of  the  155  cases  collected  by  Dr. 
Tuke  were  examples  of  the  insanity  of  lactation,  which  would  appear, 
therefore,  to  be  nearly  twice  as  common  as  that  of  pregnancy,  but 
considerably  less  so  than  the  true  puerperal  form.  Its  dependence 
on  causes  producing  anaemia  and  exhaustion  is  obvious  and  well 
marked.  In  the  large  majority  of  cases  it  occurs  in  multipart  who 
have  been  debilitated  by  frequent  pregnancies,  and  by  length  of 
nursing.  When  occurring  in  primiparse,  it  is  generally  in  women 
who  have  suffered  from  post-partum  hemorrhage,  or  other  causes  of 
exhaustion,  or  whose  constitution  was  such  as  should  have  contra- 
indicated  any  attempt  at  lactation.  The  bruit-de-diable  is  almost 
invariably  present  in  the  veins  of  the  neck,  indicating  the  im- 
poverished condition  of  the  blood. 

The  type  is  far  more  frequently  melancholic  than  maniacal,  and 
when  the  latter  form  occurs,  the  attack  is  much  more  transient  than 
in  true  puerperal  insanity.  The  danger  to  life  is  not  great,  especially 
if  the  cause  producing  debility  be  recognized  and  at  once  removed. 
There  seems,  however,  to  be  more  risk  of  the  insanity  becoming 
permanent  than  in  the  other  forms.  In  12  out  of  Dr.  Tuke's  cases 
the  melancholia  degenerated  into  dementia,  and  the  patient  became 
hopelessly  insane. 

Symptoms. — The  symptoms  of  these  various  forms  of  insanity  are 
practically  the  same  as  in  the  non-pregnant  state. 

Generally  in  cases  of  mania  there  is  more  or  less  premonitory  in- 
dication of  mental  disturbance,  which  may  pass  unperceived.  The 
attack  is  often  preceded  by  restlessness  and  loss  of  sleep,  the  latter 
being  a  very  common  and  well-marked  symptom ;  or,  if  the  patient 
do  sleep,  her  rest  is  broken  and  disturbed  by  dreams.  Causeless 
dislikes  to  those  around  her  are  often  observed ;  the  nurse,  the  hus- 
band, the  doctor,  or  the  child,  becomes  the  object  of  suspicion,  and, 


566  THE    PUERPERAL    STATE. 

unless  proper  care  be  taken,  the  child  may  be  seriously  injured.  As 
the  disease  advances,  the  patient  becomes  incoherent  and  rambling 
in  her  talk,  and,  in  a  fully -developed  case,  she  is  incessantly  pouring 
forth  an  unconnected  jumble  of  sentences,  out  of  which  no  meaning 
can  be  made.  Often  some  prevalent  idea  which  is  dwelling  in  the 
patient's  mind  can  be  traced  running  through  her  ravings,  and  it  has 
been  noticed  that  this  is  frequently  of  a  sexual  character,  causing 
women  of  unblemished  reputation  to  use  obscene  and  disgusting  lan- 
guage, which  it  is  difficult  to  understand  their  even  having  heard.  The 
tendency  of  such  patients  to  make  accusations  impugning  their  own 
chastity  was  specially  insisted  on  by  many  eminent  authorities  in  a 
recent  celebrated  trial,  when  Sir  James  Simpson  stated  that  in  his 
experience  "the  organ  diseased  gave  a  type  to  the  insanity,  so  that 
with  women  suffering  from  affections  of  the  genital  organs  the  de- 
lusions would  be  more  likely  to  be  connected  with  sexual  matters." 
Religious  delusions,  as  a  fear  of  eternal  damnation,  or  of  having 
committed  some  unpardonable  sin,  are  of  frequent  occurrence,  but 
perhaps  more  often  in  cases  which  are  tending  to  the  melancholic 
type.  There  is  generally  intolerable  restlessness,  and  the  patient's 
whole  manner  and  appearance  are  those  of  excessive  excitement. 
She  may  refuse  to  remain  in  bed,  may  tear  off  her  clothes,  or  attempt 
to  injure  herself.  The  suicidal  tendency  is  often  very  marked.  In 
one  case  under  my  care,  the  patient  made  incessant  efforts  to  destroy 
herself,  which  were  only  frustrated  by  the  most  careful  watching ; 
she  endeavored  to  strangle  herself  with  the  bedclothes,  to  swallow  any 
article  she  could  lay  hold  of,  and  even  to  gouge  out  her  own  eyes. 
Food  is  generally  persistently  refused,  and  the  utmost  coaxing  may 
fail  in  inducing  the  patient  to  take  nourishment.  The  pulse  is  rapid 
and  small,  and  the  more  violent  the  excitement  and  furious  the  de- 
lirum,  the  more  excited  is  the  circulation.  The  tongue  is  coated  and 
furred,  the  bowels  constipated  and  disordered,  and  the  feces,  as  well 
as  the  urine,  are  frequently  passed  involuntarily.  The  urine  is 
scanty  and  high-colored,  and,  after  the  disease  has  lasted  for  some 
time,  jt  becomes  loaded  with  phosphates.  The  lochia,  and  the  se- 
cretion of  milk,  generally  become  arrested  at  the  commencement  of 
the  disease.  The  waste  of  tissue,  from  the  incessant  restlessness  and 
movement  of  the  patient,  is  very  great ;  and,  if  the  disease  continue 
for  some  time,  she  falls  into  a  condition  of  marasmus,  which  may  be 
so  excessive, 


size. 

Symptoms  of  Melancholia — When  the  insanity  assumes  the  form 
of  melancholia,  its  advent  is  more  gradual.  It  may  commence  with 
depression  of  spirits,  without  any  adequate  cause,  associated  with  in- 
somnia, disturbed  digestion,  headache,  and  other  indications  of  bodily 
derangement.  Such  symptoms,  showing  themselves  in  women  who 
have  been  nursing  for  a  length  of  time,  or  in  whom  any  other  evident 
cause  of  exhaustion  exists,  should  never  pass  unnoticed.  Soon  the 
signs  of  mental  depression  increase,  and  positive  delusions  show  them- 
selves. These  may  vary  much  in  their  amount,  but  they  are  all  more 
or  less  of  the  same  type,  and  very  often  of  a  religious  character.  The 


PUERPERAL  INSANITY.  507 

amount  of  constitutional  disturbance  varies  much.  In  some  cases 
which  approach  in  character  those  of  mania,  there  is  considerable 
excitement,  rapid  pulse,  furred  tongue,  and  restlessness.  Probably 
cases  of  acute  melancholia,  coming  on  during  the  puerperal  state, 
most  often  assume  this  form.  In  others  again  there  is  less  of  these 
general  symptoms,  the  patients  are  profoundly  dejected,  sit  for  hours 
without  speaking  or  moving;  but  there  is  not  much  excitement,  and 
this  is  the  form,  most  generally  characterizing  the  insanity  of  lacta- 
tion. In  all  cases  there  is  a  marked  disinclination  to  food.  There 
is  also,  almost  invariably,  a  disposition  to  suicide ;  and  it  should 
never  be  forgotten  in  melancholic  cases  that  this  may  develop  itself 
in  an  instant,  and  that  a  moment's  carelessness  on  the  part  of  the  at- 
tendants may  lead  to  disastrous  results. 

Treatment.- — bearing  in  mind  what  has  been  said  of  the  essential 
character  of  puerperal  insanity,  it  is  obvious  that  the  course  of  treat- 
ment must  be  mainly  directed  to  maintain  the  strength  of  the  patient, 
so  as  to  enable  her  to  pass  through  the  disease  without  fatal  exhaus- 
tion of  the  vital  powers,  while  we  endeavor,  at  the  same  time,  to  calm 
the  excitement,  and  give  res-t  to  the  disturbed  brain.  Any  over- 
active  measures — for  example,  bleeding,  blistering  the  shaven  scalp, 
and  the  like — are  distinctly  contra-indicated. 

There  is  a  general  agreement  on  the  part  of  the  alienist  physicians 
that  in  cases  of  acute  mania  the  two  things  most  needful  are  a  suffi- 
cient quantity  of  suitable  food  and  sleep. 

Importance  of  Adminsteriny  Nourishment. — Every  endeavor  should 
be  made  to  induce  the  patient  to  take  abundance  of  nourishment,  to 
remedy  the  effects  of  the  excessive  waste  of  tissue,  and  support  her 
strength  until  the  disease  abates.  Dr.  Blandford,  who  has  especially 
insisted  on  the  importance  of  this,  says,1  "Now,  with  regard  to  the* 
food,  skilful  attendants  will  coax  a  patient  into  taking  a  large  quan- 
tity, and  we  can  hardly  give  too  much.  Messes  of  minced  meat  with 
potato  and  greens,  diluted  with  beef-tea,  bread  and  milk,  rum  and 
milk,  arrowroot,  and  so  on,  may  be  got  down.  Never  give  mere 
liquids  so  long  as  you  can  get  down  solids.  As  the  malady -pro- 
gresses, the  tongue  and  mouth  may  become  so  dry  and  foul  that 
nothing  but  liquids  can  be  swallowed;  but,  reserving  our  beef- tea 
and  brandy,  let  us  give  plenty  of  solid  food  while  we  can." 

Forcible  Administration  of  Food. — The  patient  may  in  mania,  as 
well  as  in  melancholia,  perhaps  even  more  in  the  latter,  obstinately 
refuse  to  take  nourishment  at  all,  and  we  may  be  compelled  to  use 
force.  Various  contrivances  have  been  employed  for  this  purpose. 
One  of  the  simplest  is  introducing  a  dessert-spoon  forcibly  between 
the  teeth,  the  patient  being  controlled  by  an  adequate  number  of 
attendants,  and  slowly  injecting  into  the  mouth  suitable  nourishment, 
by  an  india-rubber  bottle  with  an  ivory  nozzle,  such  as  is  sold  by  all 
chemists.  Care  must  be  taken  not  to  inject  more  than  an  ounce  at 
a  time,  and  to  allow  the  patient  to  breathe  between  each  deglutition. 
So  extreme  a  measure  will  seldom  be  required,  if  the  patient  have 

1  Blandford,  Insanity  and  its  Treatment. 


508  THE    PUERPERAL    STATE. 

experienced  attendants,  who  can  overcome  her  resistance  to  food  by 
gentler  means;  but  it  may  be  essential,  and  it  is  far  better  to  employ 
it  than  to  allow  the  patient  to  become  exhausted  from  want  of  nour- 
ishment. In  one  case  I  had  to  feed  a  patient  in  this  way  three  times 
a  day  for  several  weeks,  and  used  for  the  purpose  a  contrivance 
known  in  asylums  as  Paley's  feeding-bottle,  which  reduced  the  diffi- 
culty of  the  process  to  a  minimum.  Beef-tea,  or  strong  soup,  mixed 
with  some  farinaceous  material,  such  as  Revalenta  Arabica,  or  wheaten 
flour,  or  milk,  forms  the  best  mess  for  this  purpose. 

Stimulants. — In  the  early  stages  the  patient  is  probably  better 
without  stimulants,  which  seem  only  to  increase  the  excitement.  As 
the  disease  progresses,  and  exhaustion  becomes  marked,  it  may  be 
necessary  to  have  recourse  to  them.  In  melancholia  they  seem  to  be 
more  useful,  and  may  be  administered  with  greater  freedom. 

State  of  the  Bowels. — The  state  of  the  bowels  requires  especial 
attention.  They  are  almost  always  disordered,  the  evacuations 
being  dark  and  offensive  in  odor.  In  the  early  stages  "of  the  disease 
the  prompt  clearing  of  the  bowels,  by  a  suitable  purgative,  some- 
times has  the  effect  of  cutting  short  an  impending  attack.  A  curious 
example  of  this  is  recorded  by  Gooch,  in  which  the  patient's  re- 
covery seemed  to  date  from  the  free  evacuation  of  the  bowels.  A 
few  grains  of  calomel,  or  a  dose  of  compound  jalap  powder,  or  of 
castor  oil,  may  generally  be  readily  given.  During  the  continuance 
of  the  illness  the  state  of  the  primue  viae  should  be  attended  to,  and 
occasional  aperients  will  be  useful,  but  strong  and  repeated  purga- 
tion is  hurtful  from  the  debility  it  produces. 

The  procuring  sleep  will  necessarily  form  one  of  the  most  import- 
ant points  of  treatment.  For  this  purpose  there  is  no  drug  so  valu- 
able as  the  hydrate  of  chloral,  either  alone,  or  in  combination  with 
bromide  of  potassium,  which  has  a  distinct  effect  in  increasing  its 
hypnotic  action.  Given  in  a  full  dose  at  bedtime,  say  15  grs.  to  3ss, 
it  rarely  fails  in  procuring  at  least  some  sleep,  and,  in  an  early  stage 
of  acute  mania,  this  may  be  followed  by  the  best  effects.  It  may  be 
necessary  to  repeat  this  draught  night  after  night,  during  the  acute 
stage  of  the  malady.  If  we  cannot  induce  the  patient  to  swallow 
the  medicine,  it  may  be  given  in  the  form  of  enema. 

Question  of  Administering  Opiates. — It  is  generally  admitted  that 
in  mania  preparations  of  opium,  formerly  much  relied  on  in  the 
treatment  of  the  disease,  are  apt  to  do  more  harm  than  good.  Dr. 
Blandford  gives  a  strong  opinion  on  this  point.  He  says:  "In  pro- 
longed delirous  mania  I  believe  opium  never  does  good,  and  may  do 
great  harm.  We  shall  see  the  effects  of  narcotic  poisoning  if  it  be 
pushed,  but  none  that  are  beneficial.  This  applies  equally  to  opium 
given  by  the  mouth  and  by  subcutaneous  injection.  The  latter,  as 
it  is  more  certain  and  effectual  in  producing  good  results,  is  also  more 
deadly  when  it  acts  as  a  narcotic  poison.  After  the  administration 
of  a  dose  of  morphia  by  the  subcutaneous  method,  the  patient  will 
probablv  at  once  fall  asleep,  and  we  congratulate  ourselves  that  our 
long  wished-for  object  is  attained.  But  after  half  an  hour  or  so  the 
sleep  suddenly  terminates,  and  the  mania  and  excitement  are  worse 


PUERPERAL    INSANITY. 

than  before.  Here  you  may  possibly  think  that  had  the  dose  been 
larger,  instead  of  half  an  hour's  sleep  you  would  have  obtained  one 
of  longer  duration,  and  you  may  administer  more,  but  with  a  like 
result.  Large  doses  of  morphia  not  merely  fail  to  produce  refreshing- 
sleep;  they  poison  the  patient,  and  produce,  if  not  the  symptoms  of 
actual  narcotic  poisoning,  at  any  rate  that  typhoid  condition  which 
indicates  prostration  and  approaching  collapse.  I  believe  there  is 
no  drug,  the  use  of  which  more  often  becomes  abused,  than  that  of 
opium."  It  is  otherwise  in  cases  of  melancholia,  especially  in  the 
more  chronic  forms.  In  these  opiates,  in  moderate  doses,  not  pushed 
to  excess,  may  be  given  with  great  advantage.  The  subcutaneous 
injection  of  morphia  is  by  far  the  best  means  of  exhibiting  the  drug, 
from  its  rapidity  of  action,  and  facility  of  administration. 

Other  Calmatives. — There  are  other  methods  of  calming  the  excite- 
ment of  the  patient  besides  the  use  of  medicines.  The  prolonged 
use  of  the  warm  bath,  the  patient  being  immersed  in  water  at  a 
temperature  of  90°  or  92°  for  at  least  half  an  hour,  is  highly  recom- 
mended by  some  as  a  sedative.  The  wet  pack  serves  the  same  pur- 
pose, and  is  more  readily  applied  in  refractory  subjects. 

Importance  of  Judicious  Nursiny. — Judicious  nursing  is  of  primary 
importance.  The  patient  should  be  kept  in  a  cool,  well  ventilated, 
and  somewhat  darkened  room.  If  possible  she  should  remain  in  bed, 
or,  at  least,  endeavors  should  be  made  to  restrain  the  excessive  rest- 
less motion,  which  has  so  much  effect  in  promoting  exhaustion.  The 
presence  of  relatives  and  friends,  especially  the  husband,  has  gene- 
rally a  prejudicial  and  exciting  effect;  and  it  is  advisable  to  place 
the  patient  under  the  care  of  nurses  experienced  in  the  management 
of  the  insane,  who,  as  strangers,  are  likely  to  have  more  control  over 
her.  It  is  not  too  much  to  say  that  much  of  the  success  in  treatment 
must  depend  on  the  manner  in  which  this  indication  is  met.  Rough r 
unskilled  nurses,  who  do  not  know  how  to  use  gentleness  combined 
with  firmness,  will  certainly  aggravate  and  prolong  the  disorder. 
Inasmuch  as  no  patient  should  be  left  unwatched  by  day  or  night, 
more  than  one  nurse  is  essential. 

Question  of  Removal  to  an  Asylum. — The  question  of  the  removal 
of  the  patient  to  an  asylum  is  one  which  will  give  rise  to  anxious 
consideration.  As  the  fact  of  having  been  under  such  restraint  of 
necessity  fixes  a  certain  lasting  stigma  upon  a  patient,  this  is  a  step 
which  every  one  would  wish  to  avoid  if  possible.  In  cases  of  acute 
mania,  which  will  probably  last  a  comparatively  short  time,  home 
treatment  can  generally  be  efficiently  carried  out.  Much  must  depend 
on  the  circumstances  of  the  patient.  If  these  be  of  a  nature  which 
preclude  the  possibility  of  her  obtaining  thoroughly  efficient  nursing 
and  treatment  in  her  own  home,  it  is  advisable  to  remove  her  to  a 
place  where  these  essentials  can  be  obtained,  even  at  the  cost  of  some 
subsequent  annoyance.  In  cases  of  chronic  melancholia,  the  mange- 
ment  of  which  is  on  the  whole  more  difficult,  the  necessity  for  such 
a  measure  is  more  likely  to  arise,  and  should  not  be  postponed  too 
late.  Many  examples  of  incurable  dementia,  arising  out  of  puerperal 
37 


570  THE    PUERPERAL    STATE. 

melancholia,  can  be  traced  to  unnecessary  delay  in  placing  the  patients 
under  the  most  favorable  conditions  for  recovery. 

Treatment  during  Convalescence. — When  convalescence  is  com- 
mencing, change  of  air  and  scene  will  often  be  found  of  great  value. 
Kjmovai  to  some  quiet  country  place,  where  the  patient  can  enjov 
abundance  of  air  and  exercise,  in  the  company  of  her  nurses,  with- 
out the  excitement  of  seeing  many  people  is  especially  to  be  recom- 
mended. Great  caution  must  be  used  in  admitting  the  visits  of 
relatives  and  friends.  In  two  cases  under  my  own  care  the  patients 
relapsed,  when  apparently  progressing  favorably,  because  the  hus- 
bands insisted,  contrary  to  advice,  on  seeing  them.  On  the  other 
hand,  Gooch  has  pointed  out  that,  when  the  patient  is  not  recovering, 
when  month  after  month  has  been  passed  in  seclusion  without  anv 
improvement,  the  visit  of  a  friend  or  relative  may  produce  a  favor- 
able moral  impression,  and  inaugurate  a  change  for  the  better.  It  is 
probably  in  cases  of  melancholia,  rather  than  in  mania,  that  this  is 
likely  to  happen.  The  experiment  may,  under  such  circumstances, 
be  worth  trying;  but  it  is  one  the  result  of  which  we  must  contem- 
plate with  some  anxiety. 


CHAPTER  V. 

PUERPERAL   SEPTICAEMIA. 

THERE  is  no  subject  in  the  whole  range  of  obstetrics  which  has 
caused  so  much  discussion  and  difference  of  opinion  as  that  to  which 
this  chapter  is  devoted.  Under  the  name  of  "Puerperal  fever,''  the 
disease  we  have  to  consider  has  given  rise  to  endless  controversy. 
One  writer  after  another  has  stated  his  view  of  the  nature  of  the 
affection  with  dogmatic  precision,  often  on  no  other  grounds  than  his 
own  preconceived  notions,  and  an  erroneous  interpretation  of  some 
of  the  post-mortem  appearances.  Thus,  one  states  that  puerperal 
fever  is  only  a  local  inflammation,  such  as  peritonitis;  others  declare 
it  to  be  phlebitis,  metritis,  metro-peritonitis,  or  an  essential  zymotic 
disease  sui  generis,  which  affects  lying-in  women  only.  The  result 
has  been  a  hopeless  confusion :  and  the  student  rises  from  the  study 
of  the  subject  with  little  more  useful  knowledge  than  when  he  began. 
Fortunately,  modern  research  is  beginning  to  throw  a  little  light 
upon  this  chaos. 

Modern  View  of  the  Disease. — The  whole  tendency  of  recent  inves- 
tigation is  daily  rendering  it  more  and  more  certain  that  obstetri- 
cians have  been  led  into  error  by  the  special  virulence  and  intensity 
of  the  disease,  and  that  they  have  erroneously  considered  it  to  be 
something  special  to  the  puerperal  state,  instead  of  recognizing  in  it 


PUERPERAL    SEPTICAEMIA.  571 

a  form  of  septic  disease  practically  indentical  with  that  which  is 
familiar  to  surgeons  under  the  name  of  pyaemia  or  septicaemia. 

Objection  to  the  Name. — If  this  view  be  correct,  the  term  "puer- 
peral fever,"  conveying  the  idea  of  a  fever  such  as  typhus  or  typhoid, 
must  be  acknowledged  to  be  misleading,  and  one  that  should  be  dis- 
carded, as  only  tending  to  confusion.  Before  discussing  at  length 
the  reasons  which  render  it  probable  that  the  disease  is  in  no  way 
specific,  or  peculiar  to  the  puerperal  state,  it  will  be  well  to  relate 
briefly  some  of  the  leading  facts  connected  with  it. 

History  of  the  Disease.— More  or  less  distinct  references  to  the 
existence  of  the  so-called  puerperal  fever  are  met  with  in  the  classical 
authors,  proving,  beyond  doubt,  that  the  disease  was  well  known  to 
them ;  and  Hippocrates,  besides  relating  several  cases  the  nature  of 
which  is  unquestionable,  clearly  recognizes  the  possibility  of  its 
originating  in  the  retention  and  decomposition  of  portions  of  the 
placenta.  Although  Harvey  and  other  writers  showed  that  they 
were  more  or  less  familiar  with  it,  and  even  made  most  creditable 
observations  on  its  etiology,  it  was  not  until  the  latter  half  of  the  last 
century  that  it  came  prominently  into  notice.  At  that  time  the 
frightful  mortality  occurring  in  some  of  the  principal  lying-in  hos- 
pitals, especially  in  the  Hotel  Dieu  at  Paris,  attracted  attention ;  and 
ever  since  the  disease  has  been  familiar  to  obstetricians. 

Mortality  resulting  from  it  in  Lying-in  Hospitals. — Its  prevalence 
in  hospitals  in  which  lying-in  women  are  congregated  has  been  con- 
stantly observed  both  in  this  country  and  abroad,  occasionally  pro- 
ducing an  appalling  death-rate ;  the  disease,  when  once  it  has 
appeared,  frequently  spreading  from  one  patient  to  another,  in  spite 
of  all  that  could  be  done  to  arrest  it.  It  would  be  easy  to  give  many 
startling  instances  of  this.  Thus  it  prevailed  in  London  in  the  years 
1760,  1768,  and  1770,  to  such  an  extent  that  in  some  lying-in  insti- 
tutions nearly  all  the  patients  died.  Of  the  Edinburgh  Infirmary  iu 
1773,  it  is  stated  that  "  almost  every  woman,  as  soon  as  she  was  de- 
livered, or  perhaps  about  twenty -four  hours  after,  was  seized  with  it, 
and  all  of  them  died,  though  every  method  was  used  to  cure  the  dis- 
order." On  the  Continent,  where  the  lying-in  institutions  are  on  a 
much  larger  scale,  the  mortality  was  equally  great.  Thus  in  the 
Maison  cVAccouchements  of  Paris,  in  a  number  of  different  years, 
sometimes  as  many  as  1  and  3  of  the  women  delivered  died ;  on  one 
occasion  10  women  dying  out  of  15  delivered.  Similar  results  were 
observed  in  other  great  Continental  hospitals,  as  in  Vienna,  where, 
in  1823, 19  per  cent,  of  the  cases  died,  and,  in  1842, 16  per  cent. ;  and 
in  Berlin,  in  1862,  hardly  a  single  patient  escaped,  the  hospital  being 
eventually  closed. 

Such  facts,  the  correctness  of  which  is  beyond  any  question,  prove 
to  demonstration  the  great  risk  which  may  accompany  the  aggrega- 
tion of  lying-in  women.  Whether  they  justify  the  conclusion  that 
all  lying-in  hospitals  should  be  abolished,  is  another  and  a  very  wide 
question,  which  can  scarcely  be  satisfactorily  discussed  in  a  practical 
work.  It  is  to  be  observed,  however,  that  most  of  the  cases  in  which 
the  disease  produced  such  disastrous  results,  occurred  before  our  more 


572  PUERPERAL    STATE. 

recent  knowledge  of  its  mode  of  propagation  was  acquired,  when  no 
sufficient  hygienic  precautions  were  adopted,  when  ventilation  was 
little  thought  of,  and  when,  in  a  word,  every  condition  prevailed 
that  would  tend  to  favor  the  spread  of  a  contagious  disease  from  one 
patient  to  another.  More  recent  experience  proves  that  when  the 
contrary  is  the  case  (as  for  example  in  such  an  institution  as  the 
Eotunda  Hospital  in  Dublin),  the  occurrence  of  epidemics  of  this 
kind  may  be  entirely  prevented,  and  the  mortality  approximated  to 
that  of  home  practice. 

The  Assumption  of  a  Puerperal  Miasm  is  Unnecessary. — The  more 
closely  the  history  of  these  outbreaks  in  hospitals  is  studied,  the 
more  apparent  does  it  become  that  they  are  not  dependent  on  any 
miasm.  necessarily  produced  by  the  aggregation  of  puerperal  patients, 
but  on  the  direct  conveyance  of  septic  matter  from  one  patient  to 
another. 

In  numerous  instances  the  disease  has  been  said  to  be  generally 
epidemic  in  domiciliary  practice,  much  in  the  same  way  as  scarlet 
fever,  or  any  other  zymotic  complaint,  might  be.  Such  epidemics 
are  described  as  having  occurred  in  London  in  1827-28,  in  Leeds  in 
1809-12,  in  Edinburgh  in  1825,  and  many  others  might  be  cited. 
There  is,  however,  no  sufficient  ground  for  believing  that  the  disease 
has  ever  been  epidemic  in  the  strict  sense  of  the  word.  That  nume- 
rous cases  have  often  occurred  in  the  same  place,  and  at  the  same 
time,  is  beyond,  question;  but  this  can  easily  be  explained  without 
admitting  an  epidemic  influence,  knowing,  as  we  do,  how  readily 
septic  matter  may  be  conveyed  from  one  patient  to  another.  In 
many  of  the  so-called  epidemics  the  disease  has  been  limited  to  the 
patients  of  certain  midwives  or  practitioners,  while  those  of  others 
have  entirely  escaped;  a  fact  easily  understood  on  the  assumption 
of  the  disease  being  produced  by  septic  matter  conveyed  to  the 
patient,  but  irreconcilable  with  the  view  of  general  epidemic  influ- 
ence. 

Numerous  Theories  advanced  regarding  its  Nature. — It  would  be  a 
useless  task  to  detail  at  length  the  theories  that  have  been  advanced 
to  explain  the  disease.  Indeed  it  may  safely  be  held  that  the  sup- 
posed necessity  of  providing  a  theory  which  would  explain  all  the 
facts  of  the  disease  has  done  more  to  surround  it  with  obscurity  than 
even  the  difficulties  of  the  subject  itself.  If  any  real  advance  is  to 
be  made,  it  can  only  be  by  adopting  an  humble  attitude,  by  admitting 
that  we  are  only  on  the  threshold  of  the  inquiry,  and  by  a  careful 
observation  of  clinical  facts,  without  drawing  from  them  too  positive 
deductions. 

Theory  of  its  Local  Oriyin. — Many  have  taught  that  the  disease  is 
essentially  a  local  inflammation,  producing  secondary  constitutional 
effects.  This  view  doubtless  originated  from  too  exclusive  attention 
to  the  morbid  changes  found  on  post-mortem  examination.  Exten- 
sive peritonitis,  phlebitis,  inflammation  of  the  lymphatics,  or  of  the 
tissues  of  the  uterus,  are  very  commonly  found  after  death  ;  and  each 
of  these  has,  in  its  turn,  been  believecl  to  be  the  real  source  of  the 
disease.  This  view  finds  but  little  favor  with  modern  pathologists, 


PUERPERAL    SEPTICAEMIA.  573 

and  is  in  so  many  ways  inconsistent  Avith  clinical  facts,  that  it  may 
be  considered  to  be  obsolete.  No  one  of  the  conditions  above  men- 
tioned is  universally  found,  and  in  the  worst  cases,  definite  signs  of 
local  inflammation  may  be  entirely  absent.  Nor  will  this  theory 
explain  the  conveyance  of  the  disease  from  one  patient  to  another, 
or  the  peculiar  severity  of  the  constitutional  symptoms. 

Theory  of  an  Essential  Zymotic  Fever. — A  more  admissible  theory, 
and  one  which  has  been  extensively  entertained,  is,  that  there  is  an 
essential  zymotic  fever  peculiar  to,  and  only  attacking,  puerperal 
women,  which  is  as  specific  in  its  nature  as  typhus  or  typhoid,  and 
to  which  the  local  phenomena  observed  after  death  bear  the  same 
relation  that  the  pustules  on  the  skin  do  to  smallpox,  or  the  ulcers 
in  the  intestinal  glands  to  typhoid.  This  fever  is  supposed  to  spread 
by  contagion  and  infection,  and  to  prevail  epidemically,  both  in 
private  and  in  hospital  practice.  The  most  recent  exponent  of  this 
view  is  Fordyce  Barker,  Avho,  in  his  excellent  work  on  the  "Puer- 
peral Diseases,"  has  entered  at  length  into  all  the  theories  of  the 
disease.  He,  like  others  who  hold  his  opinions,  has,  I  cannot  but 
think,  entirely  failed  to  bring  forward  any  conclusive  evidence  of 
the  existence  of  such  a  specific  fever.  It  is  no  doubt  true  that  in 
typhus  and  typhoid,  and  other  undoubted  examples  of  this  class  of 
disease,  there  are  well-marked  local  secondary  phenomena;  but  then 
they  are  distinct  and  constant.  He  makes  no  attempt  to  prove  that 
anything  of  the  kind  occurs  in  puerperal  fever.  On  the  contrary, 
probably  there  are  no  two  cases  in  which  similar  local  phenomena 
occur;  nor  is  there  any  case  in  which  the  most  practised  obstetrician 
could  foretell,  either  the  course  and  duration  of  the  illness,  or  the 
local  phenomena.  Again,  this  theory  altogether  fails  to  explain  the 
very  important  class  of  cases  which  can  be  distinctly  traced  to  sources 
originating  in  the  patient  herself,  viz.,  the  absorption  of  septic  matter 
from  decomposing  coagula,  and  the  like.  Barker  meets  this  difficulty 
by  placing  such  cases  of  auto-infection  under  a  separate  category, 
admitting  that  they  are  examples  of  septicaemia.  But  he  fails  to 
show  that  there  is  any  difference  in  symptomatology  or  post-mortem 
signs  betAveen  them  and  the  cases  he  believes  to  depend  on  an  essen- 
tial fever ;  nor  would  it  be  possible  to  distinguish  the  one  from  the 
other  by  either  their  clinical  or  pathological  history. 

Theory  of  Identity  with  Surgical  Septicaemia. — The  modern  view, 
which  holds  that  the  disease  is,  in  fact,  identical  with  the  condition 
kno\vn  as  pyasrnia  or  septicaemia,  is  by  no  means  free  from  objections, 
and  much  patient  clinical  investigation  is  required  to  give  a  satisfac- 
tory explanation  of  certain  peculiarities  which  the  disease  presents ; 
but,  in  spite  of  these  difficulties,  which  time  may  serve  to  remove,  it 
offers  a  far  better  explanation  of  the  phenomena  observed  than  any 
other  that  has  yet  been  advanced. 

Nature  of  this  View. — According  to  this  theory  the  so-called  puer- 
peral fever  is  produced  by  the  absorption  of  septic  matter  into  the 
system,  through  solutions  of  continuity  in  the  generative  tract,  such 
as  ahvays  exist  after  labor.  It  is  not  essential  that  the  poison  should 
be  peculiar  or  specific;  for,  just  as  in  surgical  pyaemia,  any  decom- 


574  PUERPERAL    STATE. 

posing  organic  matter,  either  originating  within  the  generative  organs 
of  the  patient  herself,  or  coming  from  without,  may  set  up  the  morbid 
action. 

In  describing  the  disease  under  discussion,  I  shall  assume  that,  so 
far  as  our  present  knowledge  goes,  this  view  is  the  one  most  conso- 
nant with  facts;  but,  bearing  in  mind  that  very  little  is  yet  known 
of  surgical  septicaemia,  it  must  not  be  expected  that  obstetricians  can 
satisfactorily  explain  all  the  phenomena  they  observe. 

Basis  of  Description. — The  best  basis  of  description  I  know  of,  is 
that  given  by  Burdon  Sanderson,  when  he  says,  "  in  every  pysemic 
process  you  may  trace  a  focus,  a  centre  of  origin,  lines  of  diffusion  or 
distribution,  and  secondary  results  from  the  distribution.  In  every 
case  an  initial  process  from  which  infection  commences,  from  which 
the  infection  spreads,  and  secondary  processes  which  come  out  of 
this  primary  one."1  Adopting  this  division,  I  shall  first  treat  of 
the  mode  in  which  the  infection  may  commence  in  obstetric  cases, 
and  point  out  the  special  difficulties  wrhich  this  part  of  the  subject 
presents. 

Channels  through  which  Septic  Matter  may  le  Absorbed. — The  fact 
that  all  recently  delivered  women  present  lesions  of  continuity  in  the 
generative  tract,  through  which  septic  matter,  brought  into  contact 
with  them,  may  be  readily  absorbed,  has  long  been  recognized.  The 
analogy  between  the  interior  of  the  uterus  after  delivery  and  the 
surface  of  a  stump  after  operation,  wras  particularly  insisted  on  by 
Cruvelhier,  Simpson,  and  others ;  an  analogy  which  was,  to  a  great 
extent,  based  on  erroneous  conceptions  of  what  took  place,  since  they 
conceived  that  the  whole  interior  of  the  uterus  was  bared.  It  is  now 
well  known  that  that  is  not  the  case  ;  but  the  fact  remains  that  at  the 
placental  site,  at  any  rate,  there  are  open  vessels  through  which  ab- 
sorption may  readily  take  place.  That  absorption  of  septic  material 
occurs  through  this  channel  is  probable  in  certain  cases  in  which 
decomposing  materials  exist  in  the  interior  of  the  uterus,  especially 
when,  from  defective  uterine  contraction,  the  venous  sinuses  are  ab- 
normally patulous,  and  are  not  occluded  by  thrombi.  It  is  difficult 
to  understand  how  septic  matter,  introduced  from  without,  can  reach 
the  placental  site.  Other  sites  of  absorption  are,  however,  always 
available.  These  exist  in  every  case  in  the  form  of  slight  abrasions 
or  lacerations  about  the  cervix,  or  in  the  vagina,  or  especially  in 
primiparae,  about  the  fourchette  and  perineum.  There  is  even  some 
reason  to  think  that  absorption  of  septic  matter  may  take  place 
through  the  mucous  membrane  of  the  vagina  or  cervix  without  any 
breach  of  surface.  This  might  serve  to  account  for  the  occasional, 
although  rare,  cases,  in  which  symptoms  of  the  disease  develop  them- 
selves before  delivery,  or  so  soon  after  it  as  to  show  that  the  infection 
must  have  preceded  labor ;  nor  is  ther j  any  inherent  improbability 
in  the  supposition  that  septic  material  may  be  occasionally  absorbed 
through  the  unbroken  mucous  membrane,  as  is  certainly  the  case 
with  some  poisons,  for  example  that  of  syphilis.  Hence  there  is  no 

1  Clinical  Transactions,  vol.  viii.  p.  cviii. 


PUERPERAL    SEPTICAEMIA.  575 

difficulty  in  recognizing  the  similarity  of  a  lying-in  woman  to  a  pa- 
tient suffering  from  a  recent  surgical  lesion,  or  in  understanding  how 
septic  matter  conveyed  to  her,  during  or  shortly  after  labor,  may  be 
absorbed.  It  is  necessary,  however,  to  suppose  that  absorption  takes 
place  immediately  or  very  shortly  after  these  lesions  of  continuity 
are  formed,  for  it  is  well  known  that  the  power  of  absorption  is 
arrested  after  they  have  commenced  to  heal.  This  fact  may  explain 
the  cases  in  which  sloughing  about  the  perineum  or  vagina  exists 
without  any  septicaemia  resulting,  or  the  far  from  uncommon  cases, 
in  which  an  intensely  fetid  lochial  discharge  may  be  present  a  few 
days  after  delivery,  without  any  infection  taking  place. 

The  character  and  sources  of  the  septic  matter  constitute  one  of 
the  most  obscure  questions  in  connection  with  septicaemia,  and  that 
which  is  most  open  to  discussion. 

The  most  practical  division  of  the  subject  is  into  cases  in  which 
the  septic  matter  originates  within  the  patient,  so  that  she  infects 
herself,  the  disease  then  being  properly  autoyenetic ;  and  into  those 
in  which  the  septic  matter  is  conveyed  from  without,  and  brought 
into  contact  with,  absorptive  surfaces  in  the  generative  tract,  the  dis- 
ease then  being  heteroyenetic. 

Sources  of  Self-infection. — The  sources  of  auto-infection  may  be 
various,  but  they  are  not  difficult  to  understand.  Any  condition 
giving  rise  to  decomposition,  either  of  the  tissues  of  the  mother 
herself,  of  matters  retained  in  the  uterus  or  vagina  that  ought  to 
have  been  expelled,  or  decomposing  matter  derived  from  a  putrid 
foetus,  may  start  the  septicaemia  process.  Thus  it  may  happen  that, 
from  continuous  pressure  on  the  maternal  soft  parts  during  labor, 
sloughing  has  set  in;  or  there  may  be  already  decomposing  material 
present  from  some  previous  morbid  state  of  the  genital  tracts,  as  in 
carcinoma.  A  more  common  origin  is  the  retention  of  coagula,  or 
of  small  portions  of  membrane,  or  of  placenta,  in  the  interior  of  the 
uterus,  which  have  putrefied  from  access  of  air;  or  in  the  decompo- 
sition of  the  lochia.  That  the  retention  of  portions  of  the  placental 
tissue  has  at  all  times  been  the  cause  of  septicaemia  may  be  illustrated 
by  the  case  of  the  Duchesse  d'Orleans,  in  the  time  of  Louis  XIII., 
who  had  an  easy  labor,  but  died  of  child-bed  fever.  An  examination 
was  made  by  the  leading  physicians  of  Paris,  in  their  report  of  which 
it  was  stated,  "  On  the  right  side  of  the  womb  was  found  a  small 
portion  of  after-birth,  so  firmly  adherent  that  it  could  hardly  be  torn 
off  by  the  finger  nails."1  The  reason  why  self-infection  does  not 
more  often  occur  from  such  sources,  since  more  or  less  decomposition 
is  of  necessity  so  often  present,  has  already  been  referred  to  in  the 
fact  that  absorption  of  such  matters  is  not  apt  to  occur  when  the 
lesions  of  continuity,  always  existing  after  parturition,  have  com- 
menced to  heal.  This  observation  may  also  serve  to  explain  how 
previous  bad  states  of  health,  by  interfering  with  the  healthy  repa- 
rative  process  occurring  after  delivery,  may  predispose  to  self-infec- 
tion. It  is  interesting  to  note  that  puerperal  septicaemia,  arising 

1  Louise  Bourgeois,  by  Goodo!!. 


576  PUERPERAL    STATE. 

from  such  sources,  is  not  limited  to  the  human  race.  In  the  debate 
on  pyaemia  at  the  Clinical  Society  Mr.  Hutchinson  recorded  several 
well-marked  examples  occurring  in  ewes,  in  whose  uteri  portions  of 
retained  placenta  were  found. 

Source  of  Hetero genetic  Infection. — The  sources  of  sceptic  matter 
conveyed  from  without  are  much  more  difficult  to  trace,  and  there  are 
many  facts  connected  with  heterogenetic  infection  which  are  very 
difficult  to  reconcile  with  theory,  and  of  which,  it  must  be  admitted, 
we  are  not  yet  able  to  give  a  satisfactory  explanation. 

It  is  probable  that  any  decomposing  organic  matter  may  infect, 
but  that  some  forms  operate  with  more  certainty  and  greater  viru- 
lance  than  others. 

Influence  of  Cadaveric  Poisoning. — One  of  these,  which  has  attracted 
special  attention,  is  what  may  be  termed  cadaveric  poison,  derived 
from  dissection  of  the  dead  subject  in  the  anatomical  and  post-mortem 
theatre,  and  conveyed  to  the  genital  tract  by  the  hands  of  the  accou- 
cheur. Attention  was  particularly  directed  to  this  source  of  infec- 
tion by  the  observations  of  Semmelweiss,  who  showed  that  in  the 
division  of  the  Vienna  Lying-in  Hospital  attended  by  medical  men 
and  students  who  frequented  the  dissecting  rooms,  the  mortality  was 
seldom  less  than  1  in  10,  while  in  the  division  solely  attended  by 
women,  the  mortality  never  exceeded  1  in  34 ;  the  number  of  deaths 
in  the  former  division  at  once  falling  to  that  of  the  latter,  as  soon  as 
proper  precautions  and  means  of  disinfection  were  used.  Many  other 
facts  of  a  like  nature  have  since  been  recorded,  which  render  this 
origin  of  puerperal  septicaemia  a  matter  of  certainty.  An  interesting 
example  is  related  by  Simpson  with  characteristic  candor: — "In 
1836  or  1337  Mr.  Sidey  of  this  city  had  a  rapid  succession  of  five  or 
six  cases  of  puerperal  fever  in  his  practice,  at  a  time  when  the  dis- 
ease was  not  known  to  exist  in  the  practice  of  any  other  practitioners 
in  the  locality.  Dr.  Simpson,  who  had  then  no  firm  or  proper  belief 
in  the  contagious  propagation  of  puerperal  fever,  attended  the  dis- 
section of  Mr.  Sidey's  patients,  and  freely  handled  the  diseased  parts. 
The  next  four  cases  of  midwifery  which  Dr.  Simpson  attended  were 
all  affected  with  puerperal  fever,  and  it  was  the  first  time  he  had 
seen  it  in  practice.  Dr.  Patterson,  of  Leith,  examined  the  ovaries, 
etc.  The  three  next,  cases  which  Dr.  Patterson  attended  in  that  town 
were  attacked  with  the  disease.1  Negative  examples  are  of  course 
brought  forward  of  those  who  have  attended  post-mortem  examina- 
tions without  injury  to  their  obstetric  patients,  which  merely  prove 
that  the  cadaveric  poison  does  not,  of  necessity,  attach  itself  to  the 
hands  of  the  dissector  ;  and  no  amount  of  such  testimony  can  invali- 
date such  positive  evidence  as  that  just  narrated.  Barnes  believes 
that  there  is  not  so  much  danger  attending  the  dissection  of  patients 
who  have  died  of  any  ordinary  disease,  but  that  the  risk  attending 
the  dissection  of  those  who  have  died  of  infectious  or  contagions 
complaints  is  very  great  indeed.2  I  presume  there  is  no  doubt  that 

1  Selected  Obst.  Works,  p.  508. 

2  "Lectures  on  Puerperal  Fever,"  Lancet,  vol.  ii.  18C5. 


PUERPERAL    SEPTICAEMIA.  577 

the  risk  is  greater  when  the  subject  has  died  from  zymotic  disease; 
but  the  distinction  is  too  delicate  to  rely  on,  and  the  attendant  on 
midwifery  will  certainly  err  on  the  safe  side  bv  avoiding,  as  much  as 
possible,  having  anything  to  do  with  the  conduct  of  dissections  or 
post-mortern  examinations. 

Infection  from  Erysipelas. — Another  possible  source  of  infection  is 
erysipelatous  disease  in  all  its  forms.  The  intimate  connection  be- 
tween erysipelas  and  surgical  pyaemia  has  long  been  recognized  by 
surgeons,  and  the  influence  of  erysipelas  in  producing  puerperal 
Septicaemia  has  been  especially  observed  in  surgical  hospitals  in 
which  lying-in  patients  were  also  admitted.  Trousseau  relates  in- 
stances of  this  kind  occurring  in  Paris.  The  only  instance  that  I 
know  of  in  London  was  in  the  lying-in  ward  of  King's  College 
Hospital,  where,  in  spite  of  every  hygienic  precaution,  the  mortality 
was  so  great  as  to  necessitate  the  closure  of  the  ward.  Here  the 
association  of  erysipelas  with  puerperal  septicaemia  was  again  "and 
again  observed;  the  latter  proving  fatal  in  direct  proportion  to  the 
prevalence  of  the  former  in  the  surgical  wards.  The  dependence  of 
the  two  on  the  same  poison  was  in  one  instance  curiously  shown  by 
the  fact  of  the  child  of  a  patient  who  died  of  puerperal  septicaemia, 
dying  from  erysipelas  which  started  from  a  slight  abrasion  produced 
by  the  forceps.  A  more  recent  and  very  remarkable  example  is 
related  by  Dr.  Lombe  Atthill.1  A  patient  suffering  from  erysipelas 
was  admitted  into  the  Rotunda  Hospital  on  February  15, 1877.  The 
sanitary  condition  of  the  hospital  was  at  the  time  excellent.  The 
patient  was  removed  next  day;  but  of  the  next  10  patients  confined 
in  adjoining  wards,  9  were  attacked  with  puerperal  peritonitis,  the 
only  one  who  escaped  being  a  case  of  abortion.  But  the  connection 
between  erysipelas  and  puerperal  septicsernia  is  not  limited  to  hospi- 
tals, having  been  often  observed  in  domiciliary  practice.  Some 
interesting  facts  have  been  collected  by  Dr.  Minor,2  who  has  shown 
that  the  two  diseases  have  frequently  prevailed  together  in  various 
parts  of  the  United  States,  and  that  during  a  recent  outbreak  of 
puerperal  fever  in  Cincinnati,  jt  occurred  chiefly  in  the  practice  of 
those  physicians  who  attended  cases  of  erysipelas.  Many  children 
also  died  from  erysipelas,  whose  mothers  had  died  from  puerperal 
fever. 

Infection  from  other  Zymotic  Diseases. — There  is  good  reason  to 
believe  that  the  contagium  of  other  zymotic  diseases  may  produce  a 
form  of  disease  indistinguishable  from  ordinary  puerperal  septicaemia, 
and  presenting  none  of  the  characteristic  features  of  the  specific 
complaint  from  which  the  contagium  was  derived.  This  is  admitted 
to  be  a  fact  by  the  majority  of  our  most  eminent  British  obstetri- 
cians, although  it  does  not  seem  to  be  allowed  by  Continental  authori- 
ties, and  it  is  strongly  controverted  by  some  writers  in  this  country. 
It  is  certainly  difficult  to  reconcile  this  with  the  theory  of  septicas- 
mia,  and  we  are  not  in  a  position  to  give  a  satisfactory  explanation 

1  Medical  Press  and  Circular,  April,  1877. 

2  Erysipelas  and  Childbed  Fever.     Cincinnati,  1874. 


578  PUERPERAL    STATE. 

of  it.  I  believe,  however,  that  the  evidence  in  favor  of  the  possi- 
bility of  puerperal  septicaemia  originating  in  this  way  is  too  strong 
to  be  assailable. 

The  scarlatinal  poison  is  that  regarding  which  the  greatest  number 
of  observations  have  been  made.  Numerous  cases  of  this  kind  are 
to  be  found  scattered  through  our  obstetric  literature,  but  the  largest 
number  are  to  be  met  with  in  a  paper  by  Dr.  Braxton  Hicks  in  the 
12th  volume  of  the  "Obstetrical  Transactions,"  and  they  are  especi- 
ally valuable  from  that  gentleman's  well-known  accuracy  as  a  clinical 
observer.  Out  of  68  cases  of  puerperal  disease  seen  in  consultation, 
no  less  than  37  were  distinctly  traced  to  the  scarlatinal  poison.  Of 
these  20  had  the  characteristic  rash  of  the  disease ;  but  the  remain- 
ing 17,  although  the  history  clearly  proved  exposure  to  the  conta- 
gium  of  scarlet  fever,  showed  none  of  its  usual  symptoms,  and  were 
not  to  be  distinguished  from  ordinary  typical  cases  of  the  so-called 
puerperal  fever.  On  the  theory  that  it  is  impossible  for  the  specific 
contagious  diseases  to  be  modified  by  the  puerperal  state,  we  have  to 
admit  that  one  physician  met  with  17  cases  of  puerperal  septicaemia 
in  which,  by  a  mere  coincidence,  the  contagion  of  scarlet  fever  had 
been  traced,  and  that  the  disease  nevertheless  originated  from  some 
other  source ;  an  hypothesis  so  improbable,  that  its  mere  mention 
carries  its  own  refutation. 

With  regard  to  the  other  zymotic  diseases  the  evidence  is  not  so 
strong;  probably  from  the  comparative  rarity  of  the  diseases.  Hicks 
mentions  one  case  in  which  the  diphtheritic  poison  was  traced,  al- 
though none  of  the  usual  phenomena  of  the  disease  were  present.  I 
lately  saw  a  case  in  which  a  lady,  a  few  days  after  delivery,  had  a 
very  serious  attack  of  septicaemia,  without  any  diphtheritic  symp- 
toms, her  husband  being  at  the  same  time  attacked  with  diphtheria 
of  a  most  marked  type.  Here  it  would  be  difficult  not  to  admit  the 
dependence  of  the  two  diseases  on  the  same  poison. 

It  is,  however,  certain  that  all  the  zymotic  diseases  may  attack  a 
newly  delivered  woman,  and  run  their  characteristic  course  without 
any  peculiar  intensity.  Probably  most  practitioners  have  seen  cases 
of  this  kind ;  and  this  is  precisely  one  of  the  points  of  difficulty 
which  we  cannot  at  present  explain,  but  on  which  future  research 
may  be  expected  to  throw  some  light.  It  seems  to  me  not  improba- 
ble, that  the  explanation  of  the  fact  that  zymotic  poison  may  in  one 
puerperal  patient  run  its  ordinary  course,  and  in  another  produce 
symptoms  of  intense  septicaemia,  may  be  found  in  the  channel  of 
absorption.  It  is  at  any  rate  comprehensible  that  if  the  contagium 
be  absorbed  through  the  skin  or  the  ordinary  channels,  it  may  pro- 
duce its  characteristic  symptoms,  and  run  its  usual  course ;  while  if 
brought  into  contact,  with  lesions  of  continuity  in  the  generative 
tract,  it  may  act  more  in  the  way  of  septic  poison,  or  with  such  in- 
tensity that  its  specific  symptoms  are  not  developed. 

It  may  reasonably  be  objected  that  if  puerperal  and  surgical  sep- 
ticaemia be  identical,  the  zymotic  poisons  ought  to  be  similarly  modi- 
fied when  they  infect  patients  after  surgical  operations.  The  subject 
of  specific  contagium  as  a  cause  of  surgical  pyaemia  has  been  so  little 


PUERPERAL    SEPTICAEMIA.  579 

studied,  that  I  do  not  think  any  one  would  be  justified  in  asserting 
that  such  an  occurrence  is  not  possible.  Fritsch,  of  Halle,  and  other 
German  physicians,  have  recently  shown  how  elaborate  antiseptic 
precautions  in  lying-in  hospitals  may  prevent  the  origin  of  the  dis- 
ease from  such  sources.  Sir  James  Paget,  in  his  "Clinical  Lectures," 
seems  to  believe  in  the  possibility  of  such  modification.  He  says, 
"  I  think  it  not  improbable  that,  in  some  cases,  results  occurring  with 
obscure  symptoms,  within  two  or  three  days  after  operations,  have 
been  due  to  the  scarlet-fever  poison,  hindered  in  some  way  from  its 
usual  progress."  Mr.  Spencer  Wells  informs  me  that  he  has  seen 
cases  of  surgical  pygemia,  which  he  had  reason  to  believe  originated 
in  the  scarlatinal  poison  ;  and  his  well-known  success  as  an  ovario- 
tornist  is.  no  doubt,  in  a  great  measure  to  be  attributed  to  his  extreme 
care  in  seeing  that  no  one,  likely  to  come  in  contact  with  his  patients, 
has  been  exposed  to  any  such  source  of  infection. 

Septicaemia  from  Contagion  conveyed  from  other  P'uerperal  Patients. — 
The  last  source  from  which  septic  matter  may  be  conveyed  is  from  a 
patient  suffering  from  puerperal  septicaemia,  a  mode  of  origin  which 
has,  of  late,  attracted  special  attention.  That  this  is  the  explanation 
of  the  occasional  endemic  prevalence  of  the  disease  in  lying-in  hos- 
pitals can  scarcely  be  doubted.  The  theory  of  a  special  puerperal 
miasm  pervading  the  hospital  is  not  required  to  account  for  the  facts, 
for  there  are  a  hundred  ways,  impossible  to  detect  or  avoid — on  the 
hands  of  nurses  or  attendants,  in  sponges,  bed-pans,  sheets,  or  even 
suspended  in  the  atmosphere — in  which  septic  material,  derived  from 
one  patient,  may  be  carried  to  another. 

The  poison  may  be  conveyed,  in  the  same  manner,  from  one  pri- 
vate patient  to  another.  Of  this  there  are  many  lamentable  instances 
recorded.  Thus  it  was  mentioned  by  a  gentleman  at  the  recent  dis- 
cussion at  the  Obstetrical  Society,  that  5  out  of  14  women  he  attended 
died,  no  other  practitioner  in  the  neighborhood  having  a  case.  This 
origin  of  the  disease  was  clearly  pointed  out  by  Gordon1  towards  the 
end  of  last  century,  who  stated  that  he  himself  "was  the  means  of 
carrying  the  infection  to  a  great  number  of  women,"  and  he  also 
traced  the  spread  of  the  disease  in  the  same  way  in  the  practice  of 
certain  midwives.  In  some  remarkable  instances  the  unhappy  pro- 
perty of  carrying  contagion  has  clung  to  individuals  in  a  way  which 
is  most  mysterious,  and  which  has  led  to  the  supposition  that  the 
whole  system  becomes  saturated  with  the  poison.  One  of  the 
strangest  cases  of  this  kind  was  that  of  Dr.  Rutter,  of  Philadelphia, 
which  caused  much  discussion.  He  had  45  cases  of  puerperal  septi- 
caemia in  his  own  practice  in  one  year,  while  none  of  his  neighbors' 
patients  were  attacked.  Of  him  it  is  related,  "Dr.  Rutter,  to  rid 
himself  of  the  mysterious  influence  which  seemed  to  attend  upon 
his  practice,  left  the  city  for  ten  days,  and  before  waiting  on  the 
next  parturient  case  had  his  hair  shaved  off,  and  put  on  a  wig,  took 
a  hot  bath,  and  changed  every  article  of  his  apparel,  taking  nothing 
with  him  that  he  had  worn  or  carried  to  his  knowledge  on  any 

1  See  Lectures  on  Puerperal  Fever.     By  Robert  J.  Lee,  M.D. 


580  PUERPERAL    STATE. 

former  occasion:  and  mark  tlie  result.  The  lady,  notwithstanding 
that  she  had  an  easy  parturition,  was  seized  the  next  day  with  child- 
bed fever,  and  died  on  the  eleventh  day  after  the  birth  of  the  child. 
Two  years  later  he  made  another  attempt  at  self- purification,  and  the 
next  case  attended  fell  a  victim  to  the  same  disease."  No  wonder 
that  Meigs,  in  commenting  on  such  a  history,  refused  to  believe  that 
the  doctor  carried  the  poison,  and  rather  thought  that  he  was  "  merely 
unhappy  in  meeting  with  such  accidents  through  God's  providence." 
It  appears,  however,  that  Dr.  Eutter  was  the  subject  of  a  form  of 
ozcena,  and  it  is  quite  obvious  that,  under  such  circumstances,  his 
hands  could  never  have  been  free  from  septic  matter.1  [The  Author 
quotes  from  the  Editor.  Dr.  Rutter  had  an  ozcena  which  in  time  much 
disfigured  him  from  its  effect  upon  the  contour  of  his  nose.  He  was 
unfortunately  inoculated  in  his  index  finger  from  a  patient,  and 
neglected  the  pustule.  He  had  95  cases  of  puerperal  septictemia  in 
4  years  and  9  months,  with  18  deaths. — ED.]  This  observation  is 
of  peculiar  interest  as  showing  that  the  sources  of  infection  may 
exist  in  conditions  difficult  to  suspect  and  impossible  to  obviate,  and 
it  affords  a  satisfactory  explanation  of  a  case  which  was  for  years 
considered  puzzling  in  the  extreme.  It  is  quite  possible  that  other 
similar  cases,  of  which  many  are  on  record,  although  none  so  re- 
markable, may  possibly  have  depended  on  some  similar  cause  per- 
sonal to  the  medical  attendant. 

The  sources  of  septic  poison  being  thus  multifarious,  a  few  words 
may  be  said  as  to  the  mode  in  which  it  may  be  conveyed  to  the 
patient. 

Mode  in  which  the  Poison  may  be  Conveyed  to  the  Patient. — As  on 
the  view  of  puerperal  septicaemia  which  seems  most  to  agree  with 
recorded  facts,  the  poison,  from  whatever  source  it  may  be  derived, 
must  come  into  actual  contact,  with  lesions  of  continuity  in  the  gene- 
rative tract,  it  is  obvious  that  one  method  of  conveyance  may  be  on 
the  hands  of  the  accoucheur.  That  this  is  a  possibility,  and  that  the 
disease  has  often  been  unhappily  conveyed  in  this  way,  no  one  can 
doubt.  Still  it  would  be  unfair  in  the  extreme  to  conclude  that  this 
is  the  only  way  in  which  infection  may  arise.  In  town  practice, 
especially,  there  are  many  other  ways  in  which  septic  matter  may 
reach  the  patient.  The  nurse  may  be  the  means  of  communication, 
and,  if  she  have  been  in  contact  with  septic  matter,  she  is  even  more 
likely  than  the  medical  attendant  to  convey  it  when  washing  the 
genitals  during  the  first  few  days  after  delivery,  the  time  that  ab- 
sorption is  most  apt  to  occur.  Barnes  relates  a  whole  series  of  cases 
occurring  in  a  suburb  of  London,  in  the  practice  of  different  practi- 
tioners, every  one  of  which  was  attended  by  the  same  nurse.  Again 
septic  matter  may  be  carried  in  sponges,  linen,  and  other  articles. 
What  is  more  likely,  for  example,  than  that  a  careless  nurse  might  use 
an  imperfectly  washed  sponge,  on  which  discharge  .has  been  allowed 
to  remain  and  decompose  ?  Nor  do  I  see  any  reason  to  question  the 

1  This  is  stated  on  the  authority  of  an  obstetrical  contemporary  of  Dr.  Rutter. 
See  Amer.  Journ.  of  Med.  Sciences,  April,  1875,  p.  471. 


PUERPERAL    SEPTICAEMIA.  581 

possibility  of  infection  from  septic  matter  suspended  in  the  atmos- 
phere; and  in  lying-in  hospitals,  Avhere  many  women  are  congre- 
gated together,  there  can  be  little  doubt  that  this  is  a  common  origin 
of  the  disease.  It  is  certain,  whatever  view  we  may  take  of  the 
character  of  the  septic  material,  that  it  must  be  in  a  state  of  very 
minute  subdivision,  and  there  is  no  theoretical  difficulty  in  the 
assumption  of  its  being  conveyed  by  the  atmosphere. 

Conduct  of  the  Practitioner  in  relation  to  the  Disease. — This  ques- 
tion naturally  involves  a  reference  to  the  duty  of  those  who  are 
unfortunately  brought  into  contact  with  septic  matter  in  any  form, 
either  in  a  patient  suffering  from  puerperal  septicaemia,  zymotic  dis- 
ease, or  offensive  discharges.  The  practitioner  cannot  always  avoid 
such  contact,  and  it  is  practically  impossible,  as  Dr.  Duncan  has  in- 
sisted, to  relinquish  obstetric  work  every  time  that  he  is  in  attendance 
on  a  case  from  which  contagion  may  be  carried.  Nor  do  I  believe, 
especially  in  these  days  when  the  use  of  antiseptics  is  so  well  under- 
stood, that  it  is  essential.  It  was  otherwise  when  antiseptics  were 
not  employed ;  but  I  can  scarcely  conceive  any  case  in  which  the 
risk  of  infection  cannot  be  prevented  by  proper  care.  The  danger  I 
believe  to  be  chiefly  in  not  recognizing  the  possible  risk,  and  in  ne- 
glecting the  use  of  proper  precautions.  It  is  impossible,  therefore, 
to  urge  too  strongly  the  necessity  of  extreme  and  even  exaggerated 
care  in  this  direction.  The  practitioner  should  accustom  himself,  as 
much  as  possible,  to  use  the  left  hand  only  in  touching  patients  suf- 
fering from  infectious  diseases,  as  that  which  is  not  used,  under  ordi- 
nary circumstances,  in  obstetric  manipulations.  He  should  be  most 
careful  in  the  frequent  employment  of  antiseptics  in  washing  his 
hands,  such  as  Condy's  fluid,  carbolic  acid,  or  tincture  of  iodine. 
Clothing  should  be  changed  on  leaving  an  infectious  case.  Much 
more  care  than  is  usually  practised  should  be  taken  by  nurses,  espe- 
cially in  securing  perfect  cleanliness  in  every  thing  brought  into 
contact  with  the  patient.  When,  however,  a  practitioner  is  in  actual 
and  constant  attendance  on  a  case  of  puerperal  septicsemia,  when  he 
is  visiting  his  patient  many  times  a  day,  especially  if  he  be  himself 
washing  out  the  uterus  with  antiseptic  lotions,  it  is  certain  that  he 
cannot  deliver  other  patients  with  safety,  and  he  should  secure  the 
assistance  of  a  brother  practitioner,  although  there  seems  no  reason 
why  he  should  not  visit  women  already  confined,  in  whom  he  has  not 
to  make  vaginal  examinations. 

Nature  of  the  /Septic  Poison. — As  to  the  precise  character  of  the 
septic  poison — although  of  late  much  has  been  said  about  it,  and 
there  is  good  reason  to  believe  that  further  research  may  throw  light 
on  this  obscure  subject — too  little  is  known  to  justify  any  positive 
statement.  With  regard  to  the  influence  of  the  minute  organisms 
known  as  bacteria,  and  their  supposed  connection  with  the  produc- 
tion of  the  disease,  this  is  especially  the  case.  Heiberg  has  proved 
that  they  may  be  traced,  in  most  cases  of  puerperal  septicaemia,  pass- 
ing through  the  veins  and  lymphatics,  and  that  they  are  found  in 
various  organs  and  pathological  products.  But  what  their  relation 
is  to  the  disease,  whether  they  themselves  form  the  septic  matter,  or 


582  PUERPERAL    STATE. 

carry  it,  or  whether  they  are  mere  accidental  concomitants  of  the 
pysemic  process,  it  is  impossible,  in  the  present  state  of  our  know- 
ledge, to  state ;  and  I,  therefore,  prefer  to  dwell  on  that  part  of  the 
subject  which  is  of  clinical  importance,  rather  than  enter  into  specu- 
lative theories,  which  may  to-morrow  prove  to  be  valueless. 

Channels  of  Diffusion. — Passing  on  to  the  channels  of  diffusion 
through  which  the  septic  matter  may  act,  we  have  to  consider  its 
effects  on  the  structures  with  which  it  is  brought  into  contact,  and 
the  mode  in  which  it  may  infect  the  system  at  large ;  and  this  will 
include  a  consideration  of  the  pathological  phenomena. 

Local  changes  consequent  on  the  absorption  of  the  poison  are  pretty 
constant,  and  of  these  we  may  form  an  intelligible  idea  of  thinking 
of  them  as  similar  in  character  and  causation  to  those  which  we  have 
the  opportunity  of  studying  when  septic  matter  is  applied  to  a  wound 
open  to  observation,  as,  for  example,  in  cases  of  blood-poisoning  fol- 
lowing a  dissection  wound.  Distinct  traces  of  local  action  are  not  of 
invariable  occurrence,  and  in  some  of  the  worst  class  of  cases,  when 
the  amount  of  septic  matter  is  great,  and  its  absorption  rapid,  death 
may  occur  after  an  illness  of  short  duration  but  great  intensity,  and 
before  appreciable  local  changes,  either  at  the  site  of  absorption  or 
in  the  system  at  large,  have  had  time  to  develop  themselves.  The 
fact  that  puerperal  fever  may  prove  fatal,  without  leaving  any  tan- 
gible post-mortem  signs,  has  often  been  pointed  out,  such  cases  most 
frequently  occurring  during  the  endemic  prevalence  of  the  disease  in 
lying-in  hospitals.  There  can  be  little  doubt,  however,  that  in  such 
cases  of  intense  septica3mia  marked  pathological  changes  exist,  in  the 
form  of  alterations  of  the  blood  and  degenerations  of  tissue,  but  not 
of  a  character  which  can  be  detected  by  an  ordinary  post-mortem 
examination.  In  the  great  majority  of  cases,  indications  of  the  dis- 
ease exist  at  the  site  of  absorption.  These  are  described  by  patholo- 
gists  as  identical  in  their  character  with  the  inflammatory  oedema 
which  occurs  in  connection  with  phlegmonous  erysipelas.  If  lacera- 
tions exist  in  the  cervix  or  vagina  they  take  on  unhealthy  action, 
their  edges  swell,  and  their  surfaces  become  covered  with  a  yellowish 
coat,  similar  in  appearance  to  diphtheritic  membrane.  The  mucous 
membrane  of  the  uterus  is  also  generally  found  to  be  affected,  and 
in  a  degree  varying  with  the  intensity  of  the  local  septic  process. 
There  is  evidence  of  severe  endometritis ;  and,  very  frequently,  the 
whole  lining  of  the  uterus  is  profoundly  altered,  softened,  covered 
with  patches  of  diphtheritic  deposit,  and  it  may  be  in  a  state  of 
general  necrosis.  In  the  severer  cases  these  changes  affect  the  mus- 
cular tissue  of  the  uterus,  which  is  found  to  be  swollen,  soft,  imper- 
fectly contracted,  and  even  partially  necrosed,  a  condition  which  is 
likened  by  Heiberg  to  hospital  gangrene.  The  connective  tissue 
surrounding  the  generative  tract  is  also  swollen  and  oedematous,  and 
the  inflammation  may  in  this  way  reach  the  peritoneum,  although 
peritonitis,  so  often  observed  in  puerperal  septica3mia,  does  not  ne- 
cessarily depend  on  the  direct  transmission  of  inflammation  from  the 
pelvic  connective  tissue,  but  is  more  often  a  secondary  phenomenon. 

The  channels  through  which  general  systemic  infection  may  super- 


PUERPERAL    SEPTICAEMIA.  583 

vene  are  the  lymphatics  and  the  venous  sinuses,  the  former  being  by 
far  the  most  important.     Recent  researches  have  shown  the  great 
number  and  complexity  of  the  lymphatics  in  connection  with  the 
pelvic  viscera,  and  marked  traces  of  the  absorption  of  septic  matter 
are  almost  always  to  be  found,  except  in  those  very  intense  eases 
already  alluded  to,  in  which  no  appreciable  post-mortem  signs  are 
discoverable.      The  septic  matter  is  probably  absorbed  from  the 
lymph  spaces  abounding  in  the  connective  tissue,  and  carried  along 
the  lymphatic  canals  to  the  nearest  glands.     The  result  is  inflamma- 
tion of  their  coats,  and  thrombosis  of  their  contents,  which  may  be 
seen  on  section  as  a  creamy  purulent  substance.     The  absorption  of 
septic  material  may,  as  Virchow  has  shown,  be  delayed  by  the  local 
changes  produced  in  the  lymphatics  and  in  the  glands  with   which 
they  communicate,  which  are,  therefore,  conservative  in  their  action; 
and  the  further  progress  of  the  case  may  in  this  way  be  stopped,  and 
local  inflammation  alone  result,  such  cases  being  believed  by  Heiberg 
tdbe  examples  of  abortive  pyaemia.     On  the  other  hand  the  free 
septic  material  may  be  too  abundant  and  intense  to  be  so  arrested, 
it  may  pass  on  through  the  lymph  canals  and  glands,  until  it  reaches 
the  blood  current  through  the  thoracic  duct,  and  so  produces  a  gene- 
ral blood- infection.     This  mode  of  absorption  of  septic  matter,  and 
the  tendency  of  the  glands  to  arrest  its  further  progress,  serve  to 
explain  the  progressive  character  of  many  cases,  in  which  fresh 
exacerbations  seem  to  occur  from  time  to  time;  since  fresh  quantities 
of  poison,  generated  at  its  source  of  origin,  may  be  absorbed  as  the 
case  progresses.    The  uterine  veins  are  supposed  by  D'Espinne  to  be 
the  channel  of  absorption  in  the  intense  form  of  disease  which  proves 
fatal  very  shortly  after  delivery,  too  soon  for  the  more  gradual  pro- 
cess of  lymphatic  absorption  to  have  become  established.     It  is  evi- 
dent that  the  veins  are  not  likely  to  act  in  this  way,  since  they  must, 
under  ordinary  circumstances,  be  completely  occluded  by  thrombi, 
otherwise  hemorrhage  would  occur.     If,  however,  uterine  contraction 
be  incomplete,  the  occlusion  of  the  venous  sinuses  may  be  imperfect, 
and  absorption  of  septic  material  through  them  may  then  take  place. 
Some  writers  have  laid  great  stress  on  imperfect  uterine  contraction 
in  predisposing  to  septicaemia,  and  its  influence  may  thus  be  well 
explained.     The  veins  may  bear  an  important  part  in  the  production 
of  septicaemia,  independent  of  the  direct  absorption  of  septic  matter 
through  them,  by  means  of  the  detachment  of  minute  portions  of 
their  occluding  thrombi,  in  the  form  of  emboli.     If  phlegmonous 
inflammation   occur  in  the  immediate   vicinity  of  the    veins,   the 
thrombi  they  contain  may  become   infected.      When    once   blood 
infection  has  occurred,  by  any  of  these  channels,  general  septicaemia, 
the  so-called  puerperal  fever,  is  developed. 

Pathological  Phenomena  observed  after  general  Blood-infection. — 
The  variety  of  pathological  phenomena  found  on  post-mortem  ex- 
amination has  had  much  to  do  with  the  prevalent  confusion  as  to  the 
nature  of  the  disease.  This  has  resulted  in  the  description  of  many 
distinct  forms  of  puerperal  fever;  the  most  marked  pathological  alte- 
ration having  been  taken  to  be  the  essential  element  of  the  disease. 


584  PUERPERAL    STATE. 

As  a  matter  of  fact  there  is  no  doubt  that  various  types  of  pathologi- 
cal change  are  met  with.  Heiberg  describes  four  chief  classes  which 
are  by  no  means  distinctly  separated  from  one  another,  are  often 
found  simultaneously  in  the  same  subject,  and  are  certainly  not  to  be 
distinguished  by  the  symptoms  during  life. 

Intense  Cases  without  marked  Post-mortem  Kiyns. — Of  these,  the 
first  is  the  class  of  cases  in  which  no  appreciable  morbid  phenomena 
are  found  after  death.  This  formidable  and  fatal  form  of  the  disease 
has  long  been  well  known,  and  is  that  described  by  some  of  our 
authors  as  adynamia,  or  malignant  puerperal  fever.  It  is  the  variety 
which  was  so  prevalent  in  our  lying-in  hospitals,  and  which  Rams- 
botham  talks  of  as  being  second  only  to  cholera  in  the  severity  and 
suddenness  of  its  onset,  and  in  the  rapidity  with  which  it  carried  off 
its  victims.  It  is  quite  erroneous  to  suppose  that  the  existence  of 
pathological  changes  in  this  form  of  disease  has  never  been  recog- 
nized. Even  with  the  coarse  methods  of  examination  formerly  used, 
the  occurrence  of  a  fluid  and  altered  state  of  the  blood,  and  ecchy- 
moses  in  connection  with  various  organs — especially  the  lungs,  spleen, 
and  kidneys — were  noticed  and  specially  described  by  Copland  in 
his  dictionary  of  medicine.  More  recently  it  has  been  clearly  proved 
by  the  microscope  that  there  exist,  in  addition,  the  commencement 
of  inflammation  in  most  of  the  tissues,  as  shown  by  cloudy  swellings, 
and  granular  infiltration  and  disintegration  of  the  cell  elements; 
proving  that  the  blood,  heavily  charged  with  septic  matter,  had  set 
up  morbid  action  wherever  it  circulated,  the  patient  succumbing 
before  this  had  time  to  develop. 

Cases  Characterized  by  Inflammation  of  the  Serous  Membranes. — 
In  the  second  type,  and  that  perhaps  most  commonly  met  with,  the 
morbid  changes  are  most  frequently  found  in  the  serous  membranes, 
in  the  pleura, 'the  pericardium,  but,  above  all,  in  the  peritoneum,  the 
alterations  in  which  have  long  attracted  notice,  and  have  been  taken 
by  many  writers  as  proving  peritonitis  to  be  the  main  element  of  the 
disease.  Evidences  of  more  or  less  peritonitis  are  very  general.  In 
the  more  severe  cases  there  is  little  or  no  exudation  of  plastic  lymph, 
such  as  is  found  in  peritonitis  unassociated  with  septicaemia.  There 
is  a  greater  or  less  quantity  of  brownish  serum  only,  the  coils  of 
intestine,  distended  with  flatus,  and  highly  congested,  being  sur- 
rounded by  it.  More  often  there  are  patchy  deposits  of  fibrinous 
exudation  over  many  of  the  viscera,  the  fundus  uteri,  the  under  sur- 
face of  the  liver,  and  the  distended  intestines.  There  is  then  also  a 
considerable  quantity  of  sero-purulent  fluid  in  the  abdominal  cavity. 
The  pleural  cavities  may  also  exhibit  similar  traces  of  inflammatory 
action,  containing  imperfectly  organized  lymph,  and  sero-purulent 
fluid.  Schrceder  states  that  pleurisy  is  more  often  the  direct  result 
of  transmission  of  inflammation  through  the  substance  of  the  dia- 
phragm or  lung,  than  a  secondary  consequence  of  the  septicaemia. 
In  like  manner  evidences  of  pericarditis  may  exist,  the  surface  of  the 
pericardium  being  highly  injected,  and  its  cavity  containing  serous 
fluid.  Inflammation  of  the  synovial  membranes  of  the  larger  joints, 


PUERPERAL    SEPTICAEMIA.  585 

occasionally  ending  in  suppuration,  is  not  uncommon,  and  may  pro- 
bably be  best  included  under  this  class  of  cases. 

Cases  Characterized  l>y  changes  in  the  Mucous  Membrane. — In  the 
third  type  the  mucous  membranes  appear  to  bear  the  brunt  of  the 
disease.  The  pathological  changes  are  most  marked  in  the  mucous 
membrane  lining  the  intestines,  which  is  highly  congested  and  even 
ulcerated  in  patches,  with  numerous  small  spots  of  blood  extravasated 
in  the  sub-mucous  tissue.  Similar  small  apoplectic  effusions  have 
been  observed  in  the  substance  of  the  kidneys,  and  under  the  mucous 
membrane  of  the  bladder.  Pneumonia  is  of  common  occurrence. 
In  most  cases  it  is  probably  secondary  to  the  impaction  of  minute 
emboli  in  the  smaller  branches  of  the  pulmonary  artery  ;  but  it  may 
doubtless  arise  from  independent  inflammation  of  the  lung  tissue, 
and  will  then  be  included  in  the  class  of  cases  now  under  considera- 
tion. 

Cases  Characterized  by  the  Impaction  of  Infected  Emboli  and  Second- 
ary Inflammation  and  Abscess. — 'The  fourth  class  of  pathological 
phenomena  are  those  which  are  produced  chiefly  by  the  impaction 
of  minute  infected  emboli  in  small  vessels  in  various  parts  of  the 
body.  These  are  the  cases  which  most  closely  resemble  surgical 
pyosmia,  both  in  their  symptoms  and  post-mortem  signs,  and  which 
by  many  writers  are  described  under  the  name  of  puerperal  pyasmia. 
The  dependence  of  puerperal  fever  on  phlebitis  of  the  uterine  veins 
was  a  favorite  theory,  and  in  a  large  proportion  of  cases  the  coats  of 
the  veins  show  signs  of  inflammation,  their  canals  being  occupied 
with  thrombi  in  a  more  or  less  advanced  state  of  disintegration.  The 
mode  in  which  these  thrombi  may  become  infected  has  been  shown 
by  Babnoff,  who  has  proved  that  leucocytes  may  penetrate  the  coats 
of  the  vein,  and  entering  its  contained  coagulum,  may  set  up  disin- 
tegration and  suppuration.  This  observation  brings  these  pyaemic 
forms  of  disease  into  close  relation  with  septicremia,  such  as  we  have 
been  studying,  and  justifies  the  conclusion  of  Verneuil  that  purulent 
infection  is  not  a  distinct  disease,  but  only  a  termination  of  septi- 
caemia, with  which  it  ought  to  be  studied.  We  have,  moreover,  to 
differentiate  these  results  of  embolism  from  those-  considered  in  a 
subsequent  chapter ;  the  characteristic  of  these  cases  being  the  in- 
fected nature  of  the  minute  emboli.  Localized  inflammations  and 
abscesses,  from  the  impaction  of  minute  capillary  emboli,  are  found 
in  many  parts  of  the  body ;  most  frequently  in  the  lungs,  then  in 
the  kidneys,  spleen,  and  liver,  and  also  in  the  muscles  and  connective 
tissues.  Pathologists  are  by  no  means  agreed  as  to  the  invariable 
dependence  of  these  on  embolism,  nor  is  it  possible  to  prove  their 
origin  from  this  source  by  post-mortem  examination.  Some  attri- 
bute all  such  cases  to  embolism,  others  think  that  they  may  be  the 
results  of  primary  septicaemia  inflammation.  It  has  been  proved  by 
Weber  that  minute  infected  emboli  may  pass  through  the  lung- 
capillaries  ;  and  this  disposes  of  one  argument  against  the  embolic 
theory,  based  on  the  supposed  impossibility  of  their  passage.  It  is 
probable  that  both  causes  may  operate,  and  that  localized  inflamma- 
tions occurring  a  short  time  after  delivery  are  directly  produced  by 
38 


586  PUERPERAL    STATE. 

the  infected  blood,  while  those  occurring  after  the  lapse  of  some  time, 
as  in  the  second  or  third  week,  depend  upon  embolism. 

Description  of  the  Disease. — From  what  has  been  said  as  to  the 
mode  of  infection  in  puerperal  septicaemia,  and  as  to  the  very  various 
pathological  changes  which  accompany  it,  it  will  not  be  a  matter  of 
surprise  to  find  that  the  symptoms  are  also  very  various  in  different 
cases.  This  can  readily  be  explained  by  the  amount  and  virulence 
of  the  poison  absorbed,  the  channels  of  infection,  and  the  organs 
which  are  chiefly  implicated;  but  it  renders  it  very  difficult  to 
describe  the  disease  satisfactorily. 

The  symptoms  generally  show  themselves  within  two  or  three 
days  after  delivery.  As  infection  most  often  occurs  during  labor, 
or,  in  cases  which  are  autogenetic,  within  a  short  time  afterwards, 
and  before  the  lesions  of  continuity  in  the  generative  tract  have 
commenced  to  cicatrize,  it  can  be  understood  why  septicaemia  rarely 
commences  later  than  the  fourth  or  fifth  day. 

In  the  great  majority  of  cases  the  disease  begins  insidiously.  There 
are,  generally,  some  chilliness  and  rigor,  but  by  no  means  always, 
and  even  when  present  they  frequently  escape  observation,  or  are 
referred  to  some  transient  cause.  The  first  symptom  which  excites 
attention  is  a  rise  in  the  pulse,  which  may  vary  from  100  to  140  or 
more,  according  to  the  severity  of  the  attack ;  and  the  thermometer 
will  also  show  that  the  temperature  is  raised  to  102°,  or,  in  bad 
cases,  even  to  104°  or  106°.  Still,  it  must  be  borne  in  mind  that 
both  the  pulse  and  temperature  may  be  increased  in  the  puerperal 
state  from  transient  causes,  and  do  not,  of  themselves,  justify  the 
diagnosis  of  septicaemia. 

Symptoms  of  Intense  Septicaemia. — In  the  more  intense  class  of 
cases,  in  which  the  whole  system  seems  overwhelmed  with  the 
severity  of  the  attack,  the  disease  progresses  with  great  rapidity, 
and  often  without  any  appreciable  indication  of  local  complication. 
The  pulse  is  very  rapid,  small,  and  feeble,  varying  from  120  to  140, 
and  there  is  generally  a  temperature  of  103°  or  104°.  There  may 
be  little  or  no  pain,  or  there  may  be  slight  tenderness  on  pressure 
over  the  abdomen  or  uterus;  and,  as  the  disease  progresses,  the 
intestines  get  largely  distended  with  flatus,  so  that  intense  tympanites 
often  form  a  most  distressing  symptom.  The  countenance  is  sallow, 
sunken,  and  has  a  very  anxious  expression.  As  a  rule,  intelligence 
is  unimpaired,  and  this  may  be  the  case  even  in  the  worst  forms  of 
the  disease,  and  up  to  the  period  of  death.  At  other  times,  there  is 
a  good  deal  of  low  muttering  delirium,  which  often  occurs  at  night 
alone,  and  alternates  with  intervals  of  complete  consciousness,  but 
is  occasionally  intensified,  for  a  short  time,  into  a  more  acute  form. 
Diarrhoea  and  vomiting  are  of  very  frequent  occurrence;  by  the 
latter  dark,  grumous,  coffee-ground  substances  are  ejected.  The 
diarrhoea  is  occasionally  very  profuse  and  uncontrollable;  in  mild 
cases  it  seems  to  relieve  the  severity  of  the  symptoms.  The  tongue 
is  moist  and  loaded  with  sordes ;  but  sometimes  it  gets  dark  and  dry, 
especially  towards  the  termination  of  the  disease.  The  lochia  are 
generally  suppressed,  or  altered  in  character,  and  sometimes  they 
have  a  highly- offensive  odor,  especially  when  the  disease  is  auto- 


PUERPERAL    SEPTICAEMIA.  587 

genetic.  The  breathing  is  hurried  and  panting,  and  the  breath 
itself  has  a  very  characteristic,  heavy,  sweetish  odor.  The  secretion 
of  milk  is  often,  but  not  always,  arrested. 

Duration  of  the  Disease. — With  more  or  less  of  these  symptoms 
the  case  goes  on;  and  when  it  ends  fatally  it  generally  does  so 
within  a  week,  the  fatal  termination  being  indicated  by  more  weak- 
ness, rapid,  threadlike,  or  intermittent  pulse,  marked  delirium,  great 
tympanites,  and  sometimes  a  sudden  fall  of  temperature,  until  at  last 
the  patient  sinks  with  all  the  symptoms  of  profound  exhaustion. 

Variety  of  Symptoms  in  Different  Cases. — In  milder  cases  similar 
symptoms,  variously  modified  and  combined,  are  present.  It  is 
seldom  that  two  precisely  similar  cases  are  met  with ;  in  some,  the 
rapid,  weak  pulse  is  most  marked ;  in  others,  abdominal  distension, 
vomiting,  diarrhoea,  or  delirium. 

Symptoms  of  Peritonitis. — Local  complications  variously  modify 
the  symptoms  and  course  of  the  disease.  The  most  common  is  peri- 
tonitis, so  much  so  that  with  some  authors  puerperal  fever  and  puer- 
peral peritonitis  are  s}monymous  terms.  Here  the  first  symptom  is 
severe  abdominal  pain,  commencing  at  the  lower  part  of  the  abdomen, 
where  the  uterus  is  felt  enlarged  and  tender.  As  the  abdominal  pain 
and  tenderness  spread,  the  sufferings  of  the  patient  greatly  increase, 
the  intestines  become  enormously  distended  with  flatus,  and  the 
breathing  is  entirety  thoracic,  in  consequence  of  the  upward  dis- 
placement of  the  diaphragm  and  the  fact  that  the  abdominal  muscles 
are  instinctively  kept  as  much  in  repose  as  possible.  The  patient 
lies  on  her  back,  with  her  knees  drawn  up,  and  sometimes  cannot 
bear  the  slightest  pressure  of  the  bed  clothes.  There  is  generally 
much  vomiting,  and  often  severe  diarrhoea.  The  temperature  gener- 
ally ranges  from  102°  to  104°,  or  even  106°,  and  is  subject  to  occa- 
sional exacerbations  and  remissions,  possibly  depending  on  fresh 
absorption  of  septic  matter.  The  case  generally  lasts  for  a  week  or 
more,  the  symptoms  going  on  from  bad  to  worse,  and  the  patient 
dying  exhausted.  D'Espinne  points  out  that  rigors,  with  exacerba- 
tions of  the  general  symptoms,  not  unfrequently  occur  about  the 
sixth  or  seventh  day,  which  he  attributes  to  fresh  systemic  infection, 
from  foetid  pus  in  the  peritoneal  cavity.  It  must  not  be  supposed 
that  all  these  symptoms  are  necessarily  present  when  the  peritonic 
complication  exists.  Pain  especially  is  often  entirely  absent,  and  I 
have  seen  cases  in  which  post-mortem  examination  proved  the  exist- 
ence of  peritonitis  in  a  very  marked  degree,  in  which  pain  was 
entirely  absent.  Sometimes  the  pain  is  only  slight,  and  amounts  to 
little  more  than  tenderness  over  the  uterus. 

Other  local  complications  are  characterized  by  their  own  special 
symptoms ;  thus  pneumonia  by  dyspnoea,  cough,  dulness,  etc. ;  peri- 
carditis by  the  characteristic  rub  ;  pleurisy  by  dulness  on  percussion ; 
kidney  affection  by  albuminuria  and  the  presence  of  casts;  liver 
complication  by  jaundice ;  and  so  on. 

Pysemic  Forms  of  the  Disease. — The  course  of  the  disease  is  not 
always  so  intense  and  rapid,  being,  in  some  cases,  of  a  more  chronic 
character.  The  symptoms  in  the  early  stage  are  often  indistinguish- 
able from  those  already  described ;  and  it  is  generally  only  after  the 


588  PUERPERAL    STATE. 

second  week,  that  indications  of  purulent  infection  develop  them- 
selves. Then  we  often  have  recurrent  and  very  severe  rigors,  with 
marked  elevations  and  remissions  of  temperature.  At  the  same  time 
there  is  generally  an  exacerbation  of  the  general  symptoms,  a  pecu- 
liar yellowish  discoloration  of  the  skin,  and  occasionally  well- 
developed  jaundice.  Transient  patches  of  erythema  are  not  uncom- 
monly observed  on  various  parts  of  the  skin,  and  such  eruptions 
have  often  been  mistaken  for  those  of  scarlet  fever  or  other  zymotic 
disease.  Localized  inflammations  and  suppuration  may  rapidly 
follow.  Amongst  the  most  common  are  inflammation  or  even  sup- 
puration of  the  joints — the  knees,  shoulders,  or  hips — which  is  pre- 
ceded by  difficulty  of  movement,  swelling,  and  very  acute  pain. 
Large  collections  of  pus  in  various  parts  of  the  muscles  and  connec- 
tive tissues  are  not  rare.  Suppurative  inflammation  may  also  be 
found  in  connection  with  many  organs,  as  in  the  eye,  in  the  pleura, 
pericardium,  or  lungs ;  each  of  which  will,  of  course,  give  rise  to 
characteristic  symptoms,  more  or  less  modified  by  the  type  of  the 
disease  and  the  intensity  of  the  inflammation. 

Treatment. — In  considering  the  all-important  subject  of  treatment, 
the  views  of  the  practitioner  are  naturally  biased  by  the  theory  he 
has  adopted  of  the  nature  of  the  disease.  If  that  here  inculcated  be 
correct,  the  indications  we  have  to  bear  in  mind  are  :  1st,  to  discover, 
if  possible,  the  source  of  the  poison,  in  the  hope  of  arresting  further 
septic  absorption ;  2d,  to  keep  the  patient  alive  until  the  effects  of 
the  poison  are  worn  off;  and  3d,  to  treat  any  local  complications  that 
may  arise. 

The  Use  of  Antiseptic  Injections. — The  first  is  likely  to  be  of  great 
importance  in  cases  of  self-infection  as  fresh  quantities  of  septic  mat- 
ter may  be,  from  time  to  time,  absorbed.  We,  fortunately,  are  in 
possession  of  a  powerful  means  of  preventing  further  absorption  by 
the  application  of  antiseptics  to  the  interior  of  the  uterus,  and  to  the 
canal  of  the  vagina.  This  is  especially  valuable  when  the  existence 
of  decomposing  coagula,  or  other  sources  of  septic  matter,  is  sus- 
pected in  the  uterine  cavity,  or  when  offensive  discharges  are  present. 
Disinfection  is  readily  accomplished  by  washing  out  the  uterine 
cavity,  at  least  twice  daily,  by  means  of  a  Higginson's  syringe  with 
a  long  vaginal  pipe  attached.1  The  results  are  sometimes  very  re- 

1  My  colleague,  Dr.  Hayes,  has  invented  a  silver  tube  for  the  purpose  of  adminis- 
tering such  intra-uterine  injections  (Fig.  182),  which  answers  its  purpose  admirably. 

FIG.  182. 


Hayes's  Tube  for  Intra-uterine  Injections. 

The  numerous  apertures  at  its  extremity  allow  of  a  number  of  minute  streams  of  fluid 
being  thrown  out  in  the  form  of  a  spray  over  the  interior  of  the  uterus,  the  complete 


PUERPERAL    SEPTICAEMIA. 


580 


markable,  the  threatening  symptoms  rapidly  disappearing,  and  the 
temperature  and  pulse  falling  so  soon  after  the  use  of  the  antiseptic 
injections  as  to  leave  no  doubt  of  the 
beneficial    effects    of    the    treatment. 
I  cannot  better  illustrate  the  advan- 
tages of  this  treatment  than  by  the 

K. 

accompanying  temperature  chart, 
which  is  from  a  case  which  came 
under  my  observation  in  the  out-door 
practice  of  King's  College  Hospital. 
It  was  that  of  a  healthy  woman, 
thirty-six  years  of  age,  who  had  an 
easy  and  natural  labor.  Nothing  re- 
markable was  observed  until  the  3d 
day  after  delivery,  when  the  temper- 
ature was  found  to  be  slightly  in- 
creased. On  the  morning  of  the  8th  day  the  temperature  had  risen 
to  lOo.-i0.  She  was  delirious,  with  a  rapid,  thready  pulse,  clammy 
perspiration,  tympanitic  abdomen,  and  her  general  condition  indicated 
the  most  urgent  danger.  On  vaginal  examination  a  piece  of  com- 
pressed and  putrid  placenta  was  found  in  the  os.  This  was  removed 
by  my  colleague,  Dr.  Hayes,  and  the  uterus  thoroughly  washed  out 
with  Condy's  fluid  and  water.  The  same  evening  the  temperature 
had  sunk  to  99°,  and  the  general  symptoms  were  much  improved. 
The  next  day  there  was  a  slight  return  of  offensive  discharge,  and 
an  aggravation  of  the  symptoms.  After  again  washing  out  the 
uterus  the  temperature  fell,  and  from  that  date  the  patient  convalesced 
without  a  single  bad  symptom. 

This  is  a  very  well-marked  example  of  the  value  of  local  anti- 
septic treatment,  and  I  have  seen  many  cases  of  the  same  kind.  It 
should,  therefore,  never  be  omitted  in  all  cases  in  which  self-infection 
is  possible ;  and,  indeed,  even  when  there  is  no  reason  to  suspect  the 
presence  of  a  local  focus  of  infection,  the  use  of  antiseptic  lotions  is 
advisable,  as  a  matter  of  precaution,  since  it  can  do  no  harm,  and  is 
generally  comforting  to  the  patient.  Any  antiseptic  may  be  used, 
such  as  a  weak  solution  of  carbolic  acid,  or  of  tincture  of  iodine,  or 
Condy's  fluid  largely  diluted.  I  generally  use  the  two  latter  alter 
nately,  the  one  in  the  morning,  the  other  in  the  evening.  The  nozzle 
of  the  syringe  should  be  guided  well  through  the  cervix,  and  the 
cavity  of  the  uterus  thoroughly  washed  out,  until  the  fluid  that 
issues  from  the  vagina  is  no  longer  discolored.  As  the  os  is  always 
patulous,  there  is  no  'risk  of  producing  the  troublesome  symptoms 
of  uterine  colic  which  occasionally  follow  the  use  of  intra-uterine 
injections  in  the  unimpregnated  state.  It  is  quite  useless  to  entrust 
the  injection  to  the  nurse,  and  it  should  be  performed  at  least  twice 
daily  by  the  practitioner  himself,  in  all  cases  in  \vhich  the  discharges 
are  offensive. 

bathing  of  its  surface  and  washing  out  of  its  cavity  being  thus  insured.  It  is,  more- 
over, introduced  more  easily  than  the  ordinary  vaginal  pipe,  and  can  be  attached  to 
a  Higginson  syringe. 


590  THE    PUERPERAL    STATE. 

Administration  of  Food  and  Stimulants.— In  a  disease  characterized 
by  so  marked  a  tendency  to  prostration,  the  importance  of  sustaining 
the  vital  powers  by  an  abundance  of  easily  assimilated  nourishment 
cannot  be  overrated.  Strong  beef-tea,  or  other  forms  of  animal  soup, 
milk,  alone  or  mixed  either  with  lime  or  soda  water,  and  the  yolk  of 
eggs,  beat  up  with  milk  and  brandy,  should  be  given  at  short  inter- 
vals, and  in  as  large  quantities  as  the  patient  can  be  induced  to  take; 
and  the  value  of  thoroughly  efficient  nursing  will  be  specially  ap- 
parent in  the  management  of  this  important  part  of  the  treatment. 
As  there  is  frequently  a  tendency  to  nausea,  the  patient  may  resist 
the  administration  of  food,  and  the  resources  of  the  practitioner  will 
be  taxed  in  administering  it  in  such  form  and  variety  as  will  prove 
least  distasteful.  Generally  speaking,  not  more  than  one  or  two 
hours  should  be  allowed  to  elapse  without  some  nutriment  being 
given.  The  amount  of  stimulant  required  will  vary  with  the  inten- 
sity of  the  symptoms,  and  the  indications  of  debility.  Generally, 
stimulants  are  well  borne,  prove  decidedly  beneficial,  and  require  to 
be  given  pretty  freely.  In  cases  of  moderate  severity  a  tablespoonful 
of  good  old  brandy  or  whiskey  every  four  hours  may  suffice;  but 
when  the  pulse  is  very  rapid  and  thready,  when  there  is  much  low 
delirium,  tympanites,  or  sweating  (indicating  profound  exhaustion), 
it  may  be  advisable  to  give  them  in  much  larger  quantities  and  at 
shorter  intervals.  The  careful  practitioner  will  closely  watch  the 
effects  produced,  and  regulate  the  amount  by  the  state  of  the  patient, 
rather  than  by  any  fixed  rule;  but  in  severe  cases,  eight  or  twelve 
ounces  of  brandy,  or  even  more,  in  the  twenty-four  hours  may  be 
given  with  decided  benefit. 

Venesection  not  Admissible. — Venesection,  both  general  and  local, 
was  long  considered  a  sheet  anchor  in  this  disease.  Modern  views 
are,  however,  entirely  opposed  to  its  use;  and  in  a  disease  character- 
ized by  so  profound  an  alteration  of  the  blood,  and  so  much  prostra- 
tion, it  is  too  dangerous  a  remedy  to  employ,  although  it  is  possible 
that  it  might  alleviate  temporarily  the  severity  of  some  of  the 
symptoms,  especially  in  cases  in  which  peritonitis  is  well  marked, 
and  much  local  pain  and  tenderness  are  present. 

Medicinal  Treatment. — The  rational  indications  in  medicinal  treat- 
ment are  to  lessen  the  force  of  the  circulation  as  much  as  is  possible 
without  favoring  exhaustion;  and  to  diminish  the  temperature. 

Use  of  Arterial  Sedatives. — For  the  former  purpose,  Barker  strongly 
advocates  the  use  of  veratrum  viride,  in  doses  of  five  drops  of  the 
tincture  every  hour,  until  the  pulse  falls  to  below  100,  when  its 
effects  are  subsequently  kept  up  by  two  or  three  drops  every  second 
hour.  Of  this  drug  I  have  no  personal  experience;  but  I  have  ex- 
tensively used  minute  doses  of  tincture  of  aconite  for  the  same  pur- 
pose, and,  when  carefully  given,  I  believe  it  to  be  a  most  valuable 
remedy.  The  way  I  have  administered  it  is  to  give  a  single  drop  of 
the  tincture,  at  first  every  half-hour,  increasing  the  interval  of  ad- 
ministration according  to  the  effect  produced.  Generally,  after  giving 
four  or  five  doses  at  intervals  of  half  an  hour,  the  pulse  begins  to 
fall,  and  afterwards  a  few  doses,  at  intervals  of  one  or  two  hours, 


PUERPERAL    SEPTICAEMIA.  591 

will  suffice  to  prevent  the  heart's  action  rising  to  its  former  rapidity. 
The  advantage  of  thus  modifying  cardiac  action,  with  the  view  of 
preventing  excessive  waste  of  tissue,  cannot  be  questioned.  It  is 
evident  that  so  powerful  a  remedy  must  not  be  used  without  the 
most  careful  supervision,  for,  if  continued  too  long,  or  given  at  too 
frequent  intervals,  it  may  undnly  depress  the  circulation,  and  do 
more  harm  than  good.  It  is  necessary,  therefore,  that  the  practi- 
tioner should  constantly  watch  the  effect  of  the  drug,  and  stop  it  if 
the  pulse  become  very  weak,  or  if  it  intermit.  It  is  most  likely  to 
be  useful  at  an  early  stage  of  the  disease  before  much  exhaustion  is 
present,  and  then  only  when  the  pulse  is  of  a  certain  force  and 
volume.  Barker  says  of  the  veratrum  viride,  what  is  also  true  of 
aconite,  that  "it  should  not  be  given  in  those  cases  in  which  rapid 
prostration  is  manifested  by  a  feeble,  thread-like  irregular  pulse, 
profuse  sweats,  and  cold  extremities." 

Reduction  of  Temperature. — The  reduction  of  temperature  must 
form  an  important  part  of  our  treatment,  and  for  this  purpose  many 
agents  are  at  our  disposal. 

Quinine  in  large  doses,  of  from  10  to  20  grains,  has  been  much 
used  for  this  purpose,  especially  in  Germany.  After  its  exhibition 
the  temperature  frequently  falls  one  or  two  degrees.  It  may  be  given 
morning  and  evening.  Unpleasant  head-symptoms,  deafness,  and 
ringing  in  the  ears,  often  render  its  continuance  for  a  length  of  time 
impossible;  these  may,  however,  be  much  lessened  by  the  addition 
of  10  to  15  minims  of  hydrobromic  acid  to  each  dose. 

Salicylic  acid,  in  doses  of  from  10  to  20  grains,  or  the  salicylate  of 
soda  in  the  same  doses,  is  a  valuable  antipyretic,  which  I  have  found 
on  the  whole  more  manageable  than  quinine.  Under  its  use  the 
temperature  often  falls  considerably  in  a  short  space  of  time.  It  is, 
however,  apt  to  depress  the  circulation,  and  thus  requires  to  be  care- 
fully watched  while  it  is  being  administered,  and  should  the  pulse 
become  very  small  and  feeble,  it  should  be  discontinued. 

Warburg 's  Tincture. — In  some  cases,  especially  when  the  fever  has 
assumed  a  remittent  type,  I  have  administered  with  marked  benefit, 
a  drug  which  is  of  high  repute  in  India,  in  the  worst  class  of  mala- 
rious remittent  fevers,  and  the  almost  marvellous  effects  of  which  in 
such  cases  I  had  myself  witnessed  in  India  many  years  ago.  This  is 
the  so-called  Warburg's  tincture,  the  value  of  which  has  been  testified 
to  by  many  high  authorities ;  among  whom  I  may  mention  Dr.  Mac- 
lean of  Netley,  Dr.  Broadbent,  and  Sir  Alexander  Armstrong,  the 
Director-General  of  the  Medical  Department  of  the  Navy,  who  informs 
me  that  it  is  now  supplied  to  all  Her  Majesty's  ships  in  the  tropics, 
because  it  is  found  to  be  of  the  utmost  value  in  cases  in  which  quinine 
has  little  or  no  effect. 

Recently  its  composition  has  been  made  public  by  Dr.  Maclean. 
The  basis  is  quinine,  in  combination  with  various  aromatics  and  bit- 
ters, some  of  which  probably  intensify  its  action.  Be  this  as  it  may, 
the  testimony  in  favor  of  the  anti-pyretic  action  of  the  remedy  is 
very  strong.  I  have  found  its  exhibition  followed  by  a  profuse  dia- 
phoresis (this  being  its  almost  invariable  effect),  and  sometimes  a 


592  THE    PUERPERAL    STATE. 

rapid  amelioration  of  the  symptoms.  In  other  cases  in  which  I  have 
tried  it,  like  every  thing  else,  it  has  proved  of  no  avail. 

Application  of  Cold. — Cold  may  be  advantageously  tried  in  suitable 
cases.  The  simplest  mode  of  using  it  is  by  Thornton's  ice-cap,  by 
which  a  current  of  cold  water  is  kept  continuously  running  round 
the  head.  This  has  been  found  of  great  value  in  pyrexia  after  ova- 
riotomy, and  I  have  also  found  it  useful  as  a  means  of  reducing  tem- 
perature in  puerperal  cases.  It  is  a  comforting  application,  and  gives 
great  relief  to  the  throbbing  headache,  which  often  causes  much  suf- 
fering. Under  its  use  the  temperature  often  falls  two  or  more  de- 
grees, and  it  is  easily  continued  day  or  night. 

In  very  serious  cases,  when  the  temperature  reaches  105°  and  up- 
wards, the  external  application  of  cold  to  the  rest  of  the  body  may 
be  tried.  I  have  elsewhere  related  a  case  of  puerperal  septicremia 
with  hyper-pyrexia,  the  temperature  continuously  ranging  over  105°, 
in  which  I  kept  the  patient  for  eleven  days1  nearly  continuously 
covered  with  cloths  soaked  in  iced  water,  by  which  means  only  was 
the  temperature  kept  within  moderate  bounds,  and  life  preserved. 
But  this  method  of  treatment  is  excessively  troublesome,  and  is  in 
no  way  curative.  It  is  only  of  use  in  moderating  the  temperature 
when  it  has  reached  a  point  at  which  it  could  not  continue  long  with- 
out destroying  the  patient.  I  should,  therefore,  never  think  of  em- 
ploying it  unless  the  temperature  wras  over  105°,  and  then  only  as  a 
temporarv  expedient,  requiring  incessant  watching,  to  be  desisted 
from  as  soon  as  the  temperature  had  reached  a  more  moderate  height. 
It  is  clearly  impossible  to  place  a  puerperal  patient  in  a  bath,  as  is 
practised  in  hyper-pyrexia  associated  with  acute  rheumatism.  The 
same  effect  may,  however,  be  obtained  by  placing  her  on  Mackintosh 
sheeting,  and  covering  the  body  with  towels  soaked  in  iced  water, 
which  are  frequently  renewed  by  the  attendant  nurses.  During  the 
application  the  temperature  should  be  constantly  taken,  and  as  soon 
as  it  has  fallen  to  101°,  the  cold  applications  should  be  discontinued. 

Administration  of  Turpentine.  —  Amongst  other  remedies  which 
have  been  used  is  turpentine,  which  was  highly  thought  of  by  the 
Dublin  school.  In  cases  with  much  tympanitic  distension,  and  a 
small  weak  pulse,  it  is  sometimes  of  unquestionable  value,  and  it 
probably  acts  as  a  strong  nervine  stimulant.  Given  in  doses  of  15 
to  20  minims,  rubbed  up  with  mucilage,  it  can  generally  be  taken  in 
spite  of  its  nauseous  taste. 

Evacuant  Remedies. — Purgatives,  diaphoretics,  or  even  emetics, 
have  often  been  employed  as  eliminants  of  the  poison.  The  former 
are  strongly  recommended  by  Schroeder  and  other  German  authori- 
ties, and  in  this  country  they  were  formerly  amongst  the  most 
favorite  remedies.  In  the  first  volume  of  the  "Obstetrical  Journal," 
there  is  a  paper  by  Mr.  Morton,  in  which  this  practice  is  strongly 
advocated,  and  some  interesting  cases  are  recorded  in  which  it  appa- 
rently acted  well.  He  administers  calomel  in  doses  of  3  or  4  grains 

1  A  Lecture  on  a  case  of  Puerperal  Septicaemia,  with  Hyper- pyrexia,  treated  by 
the  continuous  application  of  Cold. — Brit.  Med.  Journ.,  Nov.  17,  1877. 


PUERPERAL    SEPTICAEMIA.  593 

with  compound  extract  of  colocynth,  so  as  to  keep  up  a  free  action 
of  the  bowels.  It  seems  quite  reasonable,  when  there  is  constipation, 
to  promote  a  gentle  action  of  the  bowels  by  some  mild  aperient ;  but, 
bearing  in  mind  that  severe  and  exhausting  diarrhoea  is  a  common 
accompaniment  of  the  disease,  I  should  myself  hesitate  to  run  the  risk 
of  inducing  it  artificially,  especially  as  there  is  no  proof  whatever  that 
septic  matter  can  really  be  eliminated  in  this  way.  At  the  commence- 
ment of  the  disease,  however,  1  have  often  given  one  or  two  aperient 
doses  of  calomel  with  decided  benefit. 

Internal  Antiseptic  Remedies. — It  is  possible  that  further  research 
will  give  us  some  means  of  counteracting  the  septic  state  of  the  blood, 
and  the  sulphites  and  carbolates  have  been  given  for  this  purpose, 
but  as  yet  with  no  reliable  results. 

Tincture  of  Perchloride  of  Iron. — The  tincture  of  the  perchloride 
of  iron  naturally  suggests  itself,  from  its  well-known  effects  in  surgi- 
cal pyoamia.  In  the  less  intense  forms  of  the  disease,  especially  when 
local  suppurations  exist,  it  is  certainly  useful,  and  may  be  given  in 
doses  of  10  to  20  minims  every  3  or  4  hours.  In  very  acute  cases 
other  remedies  are  more  reliable,  and  the  iron  has  the  disadvantage 
of  not  unfrequently  causing  nausea  or  vomiting. 

Opiates. — .When  restlessness,  irritation,  and  want  of  sleep  are 
prominent  symptoms,  sedatives  may  be  required.  Under  such  cir- 
cumstances opiates  may  be  given  at  night,  and  Battley's  solution, 
nepenthe,  or  the  hypodermic  injection  of  morphia,  are  the  forms 
which  answer  best. 

Treatment  of  Local  Complications. — Pain  and  tenderness,  and  local 
complications,  must  be  treated  on  general  principles.  The  distress 
from  them  is  most  experienced  when  peritonitis  is  well  marked. 
Then  warm  and  moist  applications,  in  the  form  of  poultices  or  fomen- 
tations, are  very  useful.  Eelief  is  also  sometimes  obtained  from 
turpentine  stupes,  and,  when  the  tympanites  is  distressing,  turpentine 
enemata  are  very  serviceable.  I  have  found  the  free  application 
over  the  abdomen  of  the  flexible  collodium  of  the  pharmacopoea 
decidedly  useful  in  alleviating  the  suffering  from  peritonitis. 

Such  are  the  remedies  most  used  in  the  treatment  of  this  disease. 
It  is  needless  to  say  that  it  is  quite  impossible  to  lay  down  fixed  rules 
for  the  management  of  any  individual  case;  and  it  is  obvious  that, 
if  puerperal  septicaemia  be  not  a  special  and  distinct  disease,  its  judi- 
cious management  must  depend  on  the  general  knowledge  of  the 
attendant,  and  on  a  careful  study  of  the  symptoms  each  separate  case 
presents. 


59-t  THE    PUERPERAL    STATE. 


CHAPTER  VI. 

PUERPERAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

UNDER  the  head  of  thrombosis  we  may  class  several  important 
diseases  connected  with  the  puerperal  state,  which  have  received  far 
less  attention  than  they  deserve.  It  is  only  of  late  years  that  some,  we 
may  probably  safely  say  the  majority,  of  those  terribly  sudden  deaths 
which  from  time  to  time  occur  after  delivery,  have  been  traced  to 
their  true  cause,  viz.,  obstruction  of  the  right  side  of  the  heart  and 
pulmonary  arteries  from  a  blood- clot,  either  carried  from  a  distance, 
or,  as  I  shall  hope  to  show,  formed  in  situ.  Although  the  result, 
and,  to  a  great  extent,  the  symptoms,  are  identical  in  both,  still  a 
careful  consideration  of  the  history  of  these  two  classes  of  cases  tends 
to  show  that  in  their  causation  they  are  distinct,  and  that  they  ought 
not  to  be  confounded.  In  the  former,  we  have  primarily  a  clotting 
of  blood  in  some  part  of  the  peripheral  venous  system,  and  the  sepa- 
ration of  a  portion  of  such  a  thrombus  due  to  changes  undergone 
during  retrograde  metamorphosis  tending  to  its  eventual  absorption. 
In  the  latter  we  have  a  local  deposition  of  fibrine,  the  result  of  blood 
changes  consequent  on  pregnancy  and  the  puerperal  state.  The 
formation  of  such  a  coagulum  in  vessels,  the  complete  obstruction 
of  which  is  incompatible  with  life,  explains  the  fatal  results.  When, 
however,  a  coagulum  chances  to  be  formed  in  more  distant  parts  of 
the  circulation,  the  vital  functions  are  not  immediately  interfered 
with,  and  we  have  other  phenomena  occurring,  due  to  the  obstruction. 
The  disease  known  as  phlegmasia  dolens,  I  shall  presently  attempt 
to  show,  is  one  result  of  blood-clot  forming  in  peripheral  vessels. 
But  from  the  evident  and  tangible  symptoms  it  produces  it  has  long 
been  considered  an  essential  and  special  disease,  and  the  general 
blood  dyscrasia  which  produces  it,  as  well  as  other  allied  states,  has 
not  been  studied  separately.  I  shall  hope  to  show  that  all  these 
various  conditions,  dissimilar  as  they  at  first  sight  appear,  are  very 
closely  connected,  and  that  they  are  in  fact  due  to  a  common  cause; 
and  thus,  I  think,  we  shall  arrive  at  a  clearer  and  more  correct  idea 
of  their  true  nature,  than  if  we  looked  upon  them  as  distinct  and 
separate  affections,  as  has  been  commonly  done.  I  am  aware  that 
in  phlegmasia  dolens,  the  pathology  of  which  has  received  perhaps 
more  study  than  that  of  almost  any  other  puerperal  affection,  some- 
thing beyond  simple  obstruction  of  the  venous  system  of  the  affected 
limb  is  probably  required  to  account  for  the  peculiar  tense  and 
shining  swelling  which  is  so  characteristic.  Whether  this  be  an 
obstruction  of  the  lymphatics,  as  Dr.  Tilbury  Fox  and  others  have 
maintained  with  much  show  of  reason,  or  whether  it  is  some  as  yet 
undiscovered  state,  further  investigation  is  required  to  show.  But 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  595 

it  is  beyond  any  doubt  that  the  important  and  essential  part  of  tlic 
disease  is  the  presence  of  a  thrombus  in  the  vessels;  and  I  think  it 
will  not  be  difficult  to  prove  that  in  its  causation  and  history  it  is 
precisely  similar  to  the  more  serious  cases  in  which  the  pulmonary 
arteries  are  involved. 

It  will  be  well  to  commence  the  study  of  the  subject  by  a  considera- 
tion of  the  conditions  which,  in  the  puerperal  state,  render  the  blood 
so  peculiarly  liable  to  coagulation,  and  we  may  then  proceed  to  discuss 
the  symptoms  and  results  of  the  formation  of  coagula  in  various 
parts  of  the  circulatory  system. 

Conditions  which  favor  Thrombosis, — The  researches  of  Virchow, 
Benj.  Ball,  Humphrey,  Richardson,  and  others,  have  rendered  us 
tolerably  familiar  with  the  conditions  which  favor  the  coagulation 
of  the  blood  in  the  vessels.  These  are  chiefly:  1.  A  stagnant  or 
arrested  circulation;  as,  for  example,  when  the  blood  coagulates  in 
the  veins  which  draw  blood  from  the  gluteal  region  in  old  and  bed- 
ridden people,  or  as  in  some  forms  of  pulmonary  thrombosis,  in 
which  the  clots  in  the  arteries  are  probably  the  result  of  obstruction 
in  the  circulation  through  the  lung-capillaries,  as  in  certain  cases  of 
emphysema,  pneumonia,  or  pulmonary  apoplexy.  2.  A  mechanical 
obstruction  around  which  coagula  form,  as  in  certain  morbid  states 
of  the  vessels,  or,  a  better  example  still,  secondary  coagula  which 
form  around  a  travelled  embolus  impacted  in  the  pulmonary  arteries. 
3.  And  most  important  of  all,  in  which  the  coagulation  is  the  result 
of  some  morbid  state  of  the  blood  itself.  Examples  of  this  last  con- 
dition are  frequently  met  with  in  the  course  of  various  diseases, 
such  as  rheumatism  or  fever,  in  which  the  quantity  of  fibrine  is 
increased,  and  the  blood  itself  is  loaded  with  morbid  material. 
Thrombosis  from  this  cause  is  of  by  no  means  infrequent  occurrence 
after  severe  surgical  operations,  especially  such  as  have  been  attended 
with  much  hemorrhage,  or  when  the  patient  is  in  a  weak  and  anaemic 
condition.  This  has  been  specially  dwelt  upon  as  a  not  infrequent 
source  of  death  after  operation  by  Fayrer  and  other  surgeons.1 

Conditions  ivhich  favor  Coagulation  in  the  Puerperal  State. — But 
little  consideration  is  required  to  show  why  thrombosis  plays  so  im- 
portant a  part  in  the  puerperal  state,  for  there  most  of  the  causes 
favoring  its  occurrence  are  present.  Probably  there  is  no  other  con- 
dition in  which  they  exist  in  so  marked  a  degree,  or  are  so  frequently 
combined.  The  blood  contains  an  excess  of  fibrine,  which  largely 
increases  in  the  latter  months  of  utero-gestation,  until,  as  has  been 
pointed  out  by  Andral  and  Gavarret,  it  not  unfrequently  contains  a 
third  more  than  the  average  amount  present  in  the  non-pregnant 
state.  As  soon  as  delivery  is  completed,  other  causes  of  blood  dys- 
crasia  come  into  operation.  Involution  of  the  largely  hypertrophied 
uterus  commences,  and  the  blood  is  charged  with  a  quantity  of  effete 
material,  which  must  be  present,  in  greater  or  less  amount,  until 
that  process  is  completed.  It  is  an  old  observation  that  phlegmasia 
dolens  is  of  very  common  occurrence  in  patients  who  have  lost  much 

1  Edin.  Mod.  Journ.,  March,  1861;   Indian  Annals  of  Med.,  July,  18G7. 


596  THE    PUERPERAL    STATE. 

blood  during  labor  ;  thus  Dr.  Leishman  says:  "In  no  class  of  cases 
has  it  been  so  frequently  observed  as  in  women  whose  strength  has 
been  reduced  to  a  low  ebb  by  hemorrhage  either  during  or  after 
labor ;  and  this,  no  doubt,  accounts  for  the  observation  made  by 
Merriman,  that  it  is  relatively  a  common  occurrence  after  placenta 
prsevia.1  An  examination  of  the  cases  in  which  death  results  from 
pulmonary  thrombosis  shows  the  same  facts,  as  in  a  large  proportion 
of  them  severe  post-partum  hemorrhage  has  occurred.  The  exhaus- 
tion following  the  excessive  losses  so  common  after  labor  must  of 
itself  strongly  predispose  to  thrombosis,  and,  indeed,  loss  of  blood 
has  been  distinctly  pointed  out  by  Richardson  to  be  one  of  its  most 
common  antecedents.  "  There  is,"  he  observes,  "  a  condition  which 
has  been  long  known  to  favor  coagulation  and  fibrinous  deposition. 
I  mean  loss  of  blood,  and  syncope  or  exhaustion  during  impoverished 
states  of  the  body." 

Since  then  so  many  of  the  predisposing  causes  of  thrombosis  are 
present  in  the  puerperal  state,  it  is  hardly  a  matter  of  astonishment 
that  it  should  be  of  frequent  occurrence,  or  that  it  should  lead  to 
conditions  of  serious  gravity.  And  yet  the  attention  of  the  profession 
has  been  for  the  most  part  limited  to  a  study  of  one  only  of  the 
results  of  this  tendency  to  blood-clotting  after  delivery,  no  doubt 
because  of  its  comparative  frequency  and  evident  symptoms.  True 
the  balance  of  professional  opinion  has  lately  held  that  phlegmasia 
dolens  is  chiefly  the  result  of  some  morbid  condition  of  the  blood 
producing  plugging  of  the  veins ;  but  the  wider  view  which  I  am 
attempting  to  maintain,  which  would  bring  this  disease  into  close 
relation  with  the  more  rarely  observed,  but  infinitely  important, 
obstructions  of  the  pulmonary  arteries,  has  scarcely,  if  at  all,  been 
insisted  on.  Doubtless  further  investigation  will  show  that  it  is  not 
in  these  parts  of  the  venous  system  alone  that  puerperal  thrombosis 
occurs;  but  the  symptoms  and  effects  of  venous  obstruction  else- 
where, important  though  they  may  be,  are  unknown. 

I  propose  then  to  describe  the  symptoms  and  pathology  of  blood- 
clot  in  the  right  side  of  the  heart  and  pulmonary  artery.  It  may 
be  useful  here  to  repeat  that  this  is  essentially  distinct  from  embo- 
lism of  the  same  parts.  The  latter  is  obstruction  due  to  the  impac- 
tion  of  a  separated  portion  of  a  thrombus  formed  elsewhere,  and  for 
its  production  it  is  essential  that  thrombosis  should  have  preceded  it. 
Embolism  is  in  fact  an  accident  of  thrombosis,  not  a  primary  affec- 
tion. The  condition  we  are  now  discussing  I  hold  to  be  primary, 
precisely  similar  in  its  causation  to  the  venous  obstruction  which,  in 
other  situations,  gives  rise  to  phlegmasia  dolens. 

At  the  threshold  of  this  inquiry  we  have  to  meet  the  objection, 
started  by  several  who  have  written  on  this  subject,2  that  sponta- 
neous coagulation  of  the  blood,  in  the  right  side  of  the  heart  and 
pulmonary  arteries,  is  a  mechanical  and  physiological  impossibility. 
This  was  the  view  of  Yirchow,  who,  with  his  followers,  maintained 

1  Leishman,  System  of  Obstetrics,  p.  710. 

2  See  especially  Bertin,  Des  Embolies,  p.  46  et  seq. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  597 

that  whenever  death  from  pulmonary  obstruction  occurred,  an  em- 
bolus  was  of  necessity  the  starting-point  of  the  malady,  and  the 
nucleus  round  which  secondary  deposition  of  fibrine  took  place. 
Virchow  holds  that  the  primary  factor  in  thrombosis  is  a  stagnant 
state  of  the  blood,  and  that  the  impulse  imparted  to  the  blood  by  the 
right  ventricle  is  of  itself  sufficient  to  prevent  coagulation.  It  is  to 
be  observed  that  these  objections  are  purely  theoretical.  Without 
denying  that  there  is  considerable  force  in  the  arguments  adduced,  I 
think  that  the  clinical  history  of  these  cases  strongly  favors  the  view 
of  spontaneous  coagulation ;  and  I  would  apply  to  the  theoretical 
objections  advanced  the  argument  used  by  one  of  their  strongest 
upholders,  with  regard  to  another  disputed  point,  "  Je  prefere  laisser 
la  parole  aux  faits,  car  devant  eux  la  the'orie  s'incline."1 

The  anatomical  arrangement  of  the  pulmonary  arteries  shows  how 
spontaneous  coagulation  may  be  favored  in  them ;  for,  as  Dr.  Hum- 
phrey has  pointed  out,2  "the  artery  breaks  up  at  once  into  a  number 
of  branches,  which  radiate  from  it,  at  different  angles,  to  the  several 
parts  of  the  lungs.  Consequently,  a  large  extent  of  surface  is  pre- 
sented to  the  blood,  and  there  are  numerous  angular  projections  into 
the  currents ;  both  which  conditions  are  calculated  to  induce  the 
spontaneous  coagulation  of  the  fibrine."  We  know  also,  that  throm- 
bosis generally  occurs  in  patients  of  feeble  constitution,  often  debili- 
tated by  hemorrhage,  in  whom  the  action  of  the  heart  is  much  weak- 
ened. These  facts,  of  themselves,  go  far  to  meet  the  objections  of 
those  who  deny  the  possibility  of  spontaneous  coagulation  at  the  roots 
of  the  pulmonary  arteries. 

Results  of  Post-mortem  Examinations. — The  records  of  post-mortem 
examinations  show  also,  that  in  many  of  the  cases  the  right  side  of 
the  heart,  as  well  as  the  larger  branches  of  the  pulmonary  arteries, 
contained  firm,  leathery,  decolorized,  and  laminated  coagula,  which 
could  not  have  been  recently  formed.  The  advocates  of  the  purely 
embolic  theory  maintain  that  these  are  secondary  coagula,  formed 
around  an  embolus.  But  surety  the  mechanical  causes  which  are 
sufficient  to  prevent  spontaneous  deposition  of  fibrine,  would  also 
suffice  to  prevent  its  gathering  round  an  embolus ;  unless,  indeed,  the 
obstruction  was  sufficient  to  arrest  the  circulation  altogether,  when; 
death  would  occur  before  there  was  any  time  for  secondary  deposit.. 
Before  we  can  admit  the  possibility  of  embolism  we  must  have  at 
least  one  factor,  that  is,  thrombosis  in  a  peripheral  vessel,  from  which 
an  embolus  can  come.  In  many  of  the  recorded  cases  nothing  of' 
the  kind  was  found,  and  although,  as  is  argued,  this  may  have 
been  overlooked,  yet  such  an  oversight  can  hardly  always  have  been, 
made. 

The  strongest  argument,  however,  in  favor  of  the  spontaneous 
origin  of  pulmonary  thrombosis  is  one  which  I  originally  pointed' 
out  in  a  series  of  papers  "  On  thrombosis  and  embolism  of  the  pul- 
monary artery  as  a  cause  of  death  in  the  puerperal  state."3-  I  there 

1  Bortin,  Des  Embolies,  p.  149. 

2  Humphrey,  On  the  Coagulation  of  the  Blood  in  the  Venous  System,  during  Life.. 

3  Lancet,  1867. 


598  THE    PUERPERAL    STATE. 

showed,  from  a  careful  analysis  of  25  cases  of  sudden  death  after 
delivery  in  which  accurate  post-mortem  examination  had  been  made, 
that  cases  of  spontaneous  thrombosis  and  embolism  may  be  divided 
from  each  other  by  a  clear  line  of  demarcation,  depending  on  the 
period  after  delivery  at  which  the  fatal  result  occurs.  In  7  out  of 
these  cases  there  was  distinct  evidence  of  embolism,  and  in  them 
death  occurred  at  a  remote  period  after  delivery ;  in  none  before  the 
nineteenth  day.  This  contrasts  remarkably  with  the  cases  in  which 
the  post-mortem  examination  afforded  no  evidence  of  embolism. 
These  amounted  to  15  out  of  the  25,  and  in  all  of  them,  with  one 
exception,  death  occurred  before  the  fourteenth  day,  often  on  the 
second  or  third.  The  reason  of  this  seems  to  be  that  in  the  former, 
time  is  required  to  admit  of  degenerative  changes  taking  place  in  the 
deposited  fibrine  leading  to  separation  of  an  embolus  ;  while  in  the 
latter,  the  thrombosis  corresponds  in  time,  and  to  a  great  extent  no 
doubt  also  in  cause,  to  the  original  peripheral  thrombosis  from  which, 
in  the  former,  the  embolus  was  derived.  Many  cases  I  have  since 
collected  illustrate  the  same  rule  in  a  very  curious  and  instructive 
way. 

Another  clinical  fact  I  have  observed  points  to  the  same  conclusion. 
In  one  or  two  cases  distinct  signs  of  pulmonary  obstruction  have 
shown  themselves  without  proving  immediately  fatal,  and  shortly 
afterwards,  peripheral  thrombosis,  as  evidenced  by  phlegmasia  dolens 
of  one  extremity,  has  commenced.  Here  the  peripheral  thrombosis 
obviously  followed  the  central,  both  being  produced  by  identical 
causes,  and  the  order  of  events,  necessary  to  uphold  the  purely  em- 
bolic  theory,  was  reversed. 

I  hold,  then,  that  those  who  deny  the  possibility  of  spontaneous 
coagulation  in  the  heart  and  pulmonary  arteries  do  so  on  insufficient 
grounds,  and  that  we  may  consider  it  to  be  an  occurrence,  rare  no 
doubt,  but  still  sufficiently  often  met  with,  and  certainly  of  sufficient 
importance,  to  merit  very  careful  study. 

History. — Dr.  Chas.  D.  Meigs,  of  Philadelphia,  was  one  of  the  first  to 
direct  attention  to  spontaneous  coagulation  of  the  blood  in  the  right 
side  of  the  heart  and  pulmonary  arteries,  as  a  cause  of  sudden  death 
in  the  puerperal  state.  The  occurrence  itself,  however,  has  been 
carefully  studied  by  Paget,  whose  paper  was  published  in  1845,  four 
years  before  Meigs  wrote  on  the  subject.1  It  is  true  that  none  of 
Paget's  cases  happened  after  delivery,  but  he  none  the  less  clearly 
apprehended  the  nature  of  the  obstruction.  In  1865,  Hecker2  at- 
tributed the  majority  of  these  cases  to  embolism  proper ;  and  since 
that  date  most  authors  have  taken  the  same  view,  believing  that 
spontaneous  coagulation  only  occurs  in  exceptional  cases,  such  as 
those  in  which,  on  account  of  some  obstruction  in  the  lung  or  in  the 
debility  of  the  last  few  hours  before  death,  coagula  form  in  the 
smaller  ramifications  of  the  pulmonary  arteries,  and  gradually  creep 
backwards  towards  the  heart. 

1  Medico-Chir.  Trans.,  vol.  xxvii.  p.  162,  and  vol.  xxviii.  p.  352;  Philadelphia 
iMc'dieal  Examiner,  1849. 

2  Deutsche  Klinicke,  1855. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  599 

Symptoms  of  Pulmonary  Obstruction. — The  symptoms  can  hardly 
be  mistaken,  and  there  seems  to  be  no  essential  difference  between 
the  symptomatology  of  spontaneous  and  embolic  obstruction,  so  that 
the  same  description  will  suffice  for  both.  In  a  large  proportion  of 
cases  the  attack  comes  on  with  an  appalling  suddenness  which  forms 
one  of  its  most  striking  characteristics.  Nothing  in  the  condition  of 
the  patient  need  have  given  rise  to  the  least  suspicion  of  impending 
mischief,  when,  all  at  once,  an  intense  and  horrible  dyspnoea  comes 
on  ;  she  gasps  and  struggles  for  breath  ;  tears  off  the  coverings  from 
her  chest  in  a  vain  endeavor  to  get  more  air ;  and,  often,  dies  in  a 
few  minutes,  long  before  medical  aid  can  be  had,  with  all  the  symp- 
toms of  asphyxia.  The  muscles  of  the  face  and  thorax  are  violently 
agitated  in  the  attempt  to  oxygenate  the  blood,  and  an  appearance 
closely  resembling  an  epileptic  convulsion  may  be  presented.  The 
face  may  be  either  pale  or  deeply  cyanosed.  Thus  in  one  case  I  have 
elsewhere  recorded,  which  was  an  undoubted  example  of  true  em- 
bolism, Mr.  Pedler,  the  resident  accoucheur  at  King's  College  Hos- 
pital, who  was  present  during  the  attack,  writes  of  the  patient,1 
"She  was  suffering  from  extreme  dyspnoea,  the  countenance  was 
excessively  pale,  her  lips  white,  the  face  generally  expressing  deep 
anxiety."  In  another,  which  was  probably  an  example  of  sponta- 
neous thrombosis,2  occurring  on  the  twelfth  day  after  delivery,  it  is 
stated  "  the  face  had  assumed  a  livid  purple  hue,  which  was  so  re- 
markable as  to  attract  the  attention  both  of  the  nurse  and  of  her 
mother,  who  was  with  her."  The  extreme  embarrassment  of  the  cir- 
culation is  shown  by  the  tumultuous  and  irregular  action  of  the  heart, 
in  its  endeavor  to  send  the  venous  blood  through  the  obstructed 
arteries.  Soon  it  gets  exhausted,  as  shown  by  its  feeble  and  flutter- 
ing beat.  The  pulse  is  thread-like,  and  nearly  imperceptible,  the 
respirations  short  and  hurried,  but  air  may  be  heard  entering  the 
lungs  freely.  The  intelligence  during  the  struggle  is  unimpaired ; 
and  the  dreadful  consciousness  of  impending  death  adds  not  a  little 
to  the  patient's  sufferings,  and  to.  the  terror  of  the  scene.  Such  is  an 
imperfect  account  of  the  symptoms,  gathered  from  a  record  of  what 
has  been  observed  in  fatal  cases.  It  will  be  readily  understood  why, 
in  the  presence  of  so  sudden  and  awful  an  attack,  symptoms  have  not 
been  recorded  with  the  accuracy  of  ordinary  clinical  observation. 

A  question  of  great  practical  interest,  which  has  been  entirely 
overlooked  by  writers  on  the  subject  is — Have  we  any  ground  for 
supposing  that  there  is  a  possibility  of  recovery  after  symptoms  of 
pulmonary  obstruction  have  developed  themselves?  That  such  a 
result  must  be  of  extreme  rarity  is  beyond  question ;  but  I  have 
little  doubt  that  in  some  few  cases,  entirely  inexplicable  on  any  other 
hypothesis,  life  is  prolonged  until  the  coagulum  is  absorbed,  and  the 
pulmonary  circulation  restored.  In  order  to  admit  of  this  it  is,  of 
course,  essential  that  the  obstruction  be  not  sufficient  to  prevent  the 
passage  of  a  certain  quantity  of  blood  to  the  lungs,  to  carry  on  the 
vital  functions.  The  history  of  many  cases  tends  to  show  that  the 

1  Brit.  Med.  Journ.,  March  27,  1869.  2  Obst.  Trans.,  vol.  xii.  p.  194. 


600  THE    PUERPERAL    STATE. 

obstructing  clot  was  present  for  a  considerable  time  before  death,  and 
that  it  was  only  when  some  sudden  exertion  was  made,  such  as  rising 
from  bed  or  the  like,  calling  for  an  increased  supply  of  blood  which 
could  not  pass  through  the  occluded  arteries,  that  fatal  symptoms 
manifested  themselves.  This  was  long  ago  pointed  out  by  Paget,1 
who  says,  "  The  case  proves  that,  in  certain  circumstances,  a  great 
part  of  the  pulmonary  circulation  may  be  arrested  in  the  course  of  a 
week  (or  a  few  days  more  or  less),  without  immediate  danger  to  life, 
or  any  indication  of  what  had  happened."  And,  after  referring  to 
some  illustrative  cases,  "  Yet  in  all  these  cases  the  characters  of  the 
clots  by  which  the  pulmonary  arteries  were  obstructed,  showed 
plainly  that  they  had  been  a  week  or  more  in  the  process  of  forma- 
tion." If  we  admit  the  possibility  of  the  continuance  of  life  for  a 
certain  time,  we  must,  I  think,  also  admit  the  possibility,  in  a  few 
rare  cases,  of  eventful  complete  recovery.  What  is  required  is  time 
for  the  absorption  of  the  clot.  In  the  peripheral  venous  system 
coagula  are  constantly  removed  by  absorption.  So  strong,  indeed, 
is  the  tendency  to  this,  that  Humphrey  observes  with  regard  to  it, 
'"  It  appears  that  the  blood  is  almost  sure  to  revert  to  its  natural 
channel  in  process  of  time."2  If  then  the  obstruction  be  only  par- 
tial, if  sufficient  blood  pass  to  keep  the  patient  alive,  and  a  sudden 
supply  of  oxygenated  blood  is  not  demanded  by  any  exertion  which 
the  embarrassed  circulation  is  unable  to  meet,  it  is  not  inconceivable 
that  the  patient  may  live  until  the  obstruction  is  removed. 

Illustrative  Cases. — Such,  I  believe,  to  be  the  only  explanation  of 
certain  cases,  some  of  which,  on  any  other  hypothesis,  it  is  impossible 
to  understand.  The  symptoms  are  precisely  those  of  pulmonary 
obstruction,  and  the  description  I  have  given  above  may  be  applied 
to  them  in  every  particular;  and,  after  repeated  paroxysms,  each  of 
which  seems  to  threaten  immediate  dissolution,  an  eventual  recovery 
takes  place.  What  then,  I  am  entitled  to  ask,  can  the  condition  be, 
if  not  that  which  I  suggest?  As  the  question  I  am  considering  has 
never,  so  far  as  I  am  aw,are,  been  treated  of  by  any  other  writer,  I 
may  be  permitted  to  state,  very  briefly,  the  facts  of  one  or  two  of 
the  cases  on  which  I  found  my  argument,  some  of  which  I  have 
already  published  in  detail  elsewhere. 

K.  H.,  delicate  young  lady.  Labor  easy.  First  child.  Profuse  post-partum 
hemorrhage.  Did  well  until  the  7th  day,  during  the  whole  of  which  she  felt  wi-nk. 
Same  day  an  alarming  attack  of  dyspnoea  came  on.  For  several  days  she  remained 
in  a  very  critical  condition,  the  slightest  exertion  bringing  on  the  attacks.  A  slight 
blowing  murmur  heard  for  a  few  days  at  the  base  of  the  heart,  and  then  disappeared. 
For  two  months  patient  remained  in  the  same  state.  As  long  as  she  was  in  the 
recumbent  position  she  felt  pretty  comfortable;  but  any  attempt  at  sitting  up  in  bed, 
or  any  unusual  exertion,  immediately  brought  on  the  embarrassed  respiration.  During 
all  this  time  it  was  found  necessary  to  administer  stimulants  profusely  to  ward  off'  the 
attacks.  Eventually  the  patient  recovered  completely. 

Q.  F.,  set.  44.  Mother  of  twelve  children.  Confined  on  July  6.  On  the  llth 
day  she  went  to  bed  feeling  well.  There  was  no  swelling  or  discomfort  of  any  kind 
about  the  lower  extremities  at  this  time.  About  half-past  3  A.M.  she  was  sitting  up 
in  bed,  when  she  was  suddenly  attacked  with  an  indescribable  sense  of  oppression  in 


1  Op.  cit.,  p.  358.  2  Med.  Chir.  Trans.,  vol.  xxvii,  p.  14. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM.  G01 

the  chest,  and  fell  back  in  a  semi-unconscious  state,  gasping  for  breath.  She  re- 
mained in  a  very  critieal  condition,  with  the  same  symptoms  of  embarrassed  respira- 
tion, for  three  days,  when  they  gradually  passed  away.  Two  days  after  the  attack, 
phlegmasia  dolens  came  on,  the  leg  swelled,  and  remained  so  for  several  months. 

This  case  is  an  example  of  the  fact  I  have  already  referred  to,  of 
phlegmasia  dolens  coming  on  after  the  symptoms  of  pulmonary 
obstruction  had  manifested  themselves ;  the  inference  being  that 
both  depended  on  similar  causes  operating  on  two  distinct  parts  of 
the  circulatory  system. 

C.  H.,  set.  24.  Confined  of  her  first  child  on  August  20,  1867.  Thirty  hours 
after  delivery  she  complained  of  great  weakness  and  dyspnoea.  This  Avas  alleviated 
by  the  treatment  employed,  but  on  the  ninth  day,  after  making  a  sudden  exertion, 
the  dyspnoea  returned  with  increased  violence,  and  continued  unabated  until  I  saw 
the  patient  on  September  4,  fourteen  days  after  her  confinement.  The  following 
are  the  notes  of  her  condition  made  at  the  time  of  the  visit:  "I  found  her  sitting  on 
the  sofa,  propped  up  with  pillows,  as  she  said  she  could  not  breathe  in  the  recumbent 
position.  The  least  excitement  or  talking  brought  on  the  most  aggravated  dyspnoea, 
which  was  so  bad  as  to  threaten  almost  instant  death.  Her  sufferings  during  these 
paroxysms  were  terrible  to  witness.  She  panted  and  struggled  for  breath,  and  her 
chest  heaved  with  short  gasping  respirations.  She  could  not  even  bear  any  one  to 
stand  in  front  of  her,  waving  them  away  with  her  hand,  and  calling  for  more  air. 
These  attacks  were  very  frequent,  and  were  brought  on  by  the  most  trivial  causes. 
She  talked  in  a  low  suppressed  voice,  as  if  she  could  not  spare  breath  for  articulation. 
On  auscultation  air  was  found  to  enter  the  lungs  freely  in  every  direction,  both  in 
front  and  behind.  Immediately  over  the  site  of  the  pulmonary  arteries  there  was  a 
distinct  harsh,  rasping  murmur,  confined  to  a  very  limited  space,  and  not  propagated 
either  upwards  or  downwards.  The  heart-sounds  were  feeble  and  tumultuous." 
These  symptoms  led  me  to  diagnose  pulmonary  obstruction,  and  I,  of  course,  gave 
a  most  unfavorable  prognosis,  but  to  my  great  surprise  the  patient  slowly  recovered. 
I  saw  her  again  six  weeks  later,  when  her  heart-sounds  were  regular  and  distinct, 
and  the  murmur  had  completely  disappeared. 

E.  E.,  set.  42,  was  confined  for  the  first  time  on  November  5,  1873,  in  the  sixth 
month  of  utero-gestation.  She  had  severe  post^partum  hemorrhage,  depending  on 
partially  adherent  placenta,  which  was  removed  artificially.  She  did  perfectly  well 
until  the  14th  day  after  delivery,  when  she  was  suddenly  attacked  with  intense 
dyspnoea,  aggravated  in  paroxysms.  Pulse  pretty  full,  130,  but  distinctly  inter- 
mittent. Air  entered  lungs  freely.  The  heart's  action  was  fluttering  and  irregular, 
and,  at  the  juncture  of  the  fourth  and  fifth  ribs  with  the  sternum,  there  was  a  loud 
blowing  systolic  murmur.  This  was  certainly  non-existent  before,  as  the  heart  had 
been  carefully  auscultated  before  administering  chloroform  during  labor.  For  two 
days  the  patient  remained  in  the  same  state,  her  death  being  almost  momentarily 
expected.  On  the  21st,  that  is  two  days  after  the  appearance  of  the  chest  symptoms, 
phlegmasia  dolens  of  a  severe  kind  developed  itself  in  the  right  thigh  and  leg.  She 
continued  in  the  same  state  for  many  days,  lying  more  or  less  tranquilly,  but  having 
paroxysms  of  the  most  intense  apnoea,  varying  from  two  to  six  or  eight  in  the  twenty- 
four  hours.  No  one  who  saw  her  in  one  of  these  could  have  expected  her  to  live 
through  it.  Shortly  after  the  first  appearance  of  the  paroxysms  it  was  observed  that 
the  cellular  tissue  of  the  neck  and  part  of  the  face  became  sw6llen  and  oedematous, 
giving  an  appearance  not  unlike,  that  of  phlegmasia  dolens.  The  attacks  were  always 
relieved  by  stimulants.  These  she  incessantly  called  for,  declaring  that  she  felt  they 
kept  her  alive.  During  all  this  time  the  mind  was  clear  and  collected.  The  pulse 
varied  from  110  to  130.  Respirations  about  GO,  temperature  101°  to  102.5°.  By 
slow  degrees  the  patient  seemed  to  be  rallying.  The  paroxysms  diminished  in  nurr.- 
ber,  and  after  December  1  she  never  had  another,  and  the  breathing  became  free 
and  easy.  The  pulse  fell  to  80,  and  the  cardiac  murmur  entirely  disappeared.  The 
patient  remained,  however,  very  weak  and  feeble,  and  the  debility  seemed  to  increase. 
Towards  the  second  week  in  December  she  became  delirious,  and  died,  apparently 
exhausted,  without  any  fresh  chest  symptoms,  on  the  19th  of  that  month.  No  post- 
mortem examination  was  allowed. 
39 

l-K.YSllM/,Kii  ifcl£Ub!.S 

I     1'  S      ;,   Iv  I'  I     Lbb',   U  ,    £,  /i. 


602  THE    PUERPERAL    STATE. 

I  have  narrated  this  case,  although  it  terminated  fatally,  because 
I  hold  it  to  be  one  of  the  class  I  am  considering.  The  death  was 
certainly  not  due  to  the  obstruction,  all  symptoms  of  which  had 
disappeared,  but  apparently  to  exhaustion  from  the  severity  of  the 
former  illness.  It  illustrates  too  the  simultaneous  appearance  of 
symptoms  of  pulmonary  obstruction  and  peripheral  thrombosis. 
The  swelling  of  the  neck  was  a  curious  symptom,  which  has  not 
been  recorded  in  any  other  cases,  and  may  possibly  be  a  further  proof 
of  the  analogy  between  this  condition  and  phlegmasia  dolens. 

Now,  it  may,  of  course,  be  argued  that  these  cases  do  not  prove 
my  thesis,  inasmuch  as  I  only  assume  the  presence  of  a  coagulum. 
But  I  may  fairly  ask  in  return  what  other  condition  could  possibly 
explain  the  symptoms?  They  are  precisely  those  which  are  noticed 
in  death  from  undoubted  pulmonary  obstruction.  No  one  seeing 
one  of  them,  or  even  reading  an  account  of  the  symptoms,  while 
ignorant  of  the  result,  could  hesitate  a  single  instant  in  the  diagnosis. 
Surely,  then,  the  inference  is  fair  that  they  depended  on  the  same 
cause?  In  the  very  nature  of  things  my  hypothesis  cannot  be  veri- 
fied by  post-mortern  examination;  but  there  is  at  least  one  case  on 
record,  in  which,  after  similar  symptoms,  a  clot  was  actually  found. 
The  case  is  related  by  Dr.  Richardson.1  It  was  that  of  a  man  who 
for  weeks  had  symptoms  precisely  similar  to  those  observed  in  the 
cases  I  have  narrated.  In  one  of  his  agonizing  struggles  for  breath 
he  died,  and  after  death  it  was  found  "that  a  fibrinous  band,  having 
its  hold  in  the  ventricle,  extended  into  the  pulmonary  artery."  This 
observation  proves  to  a  certainty  that  life  may  continue  for  weeks 
after  the  deposition  of  a  coagulum ;  and,  moreover,  this  condition 
was  precisely  what  we  should  anticipate,  since,  of  course,  the  ob- 
structing coagulum  must  necessarily  be  small,  otherwise  the  vital 
functions  would  be  immediately  arrested. 

Cardiac  Murmurs  in  Pulmonary  Obstruction. — There  is  a  symptom 
noted  in  two  of  the  above  cases,  and  to  less  extent  in  a  third,  which 
has  not  been  mentioned  in  any  account  of  fatal  cases  occurring  after 
delivery,  viz.,  a  murmur  over  the  site  of  the  pulmonary  arteries. 
It  is  a  sign  we  should  naturally  expect,  and  very  possibly  it  would 
be  met  with  in  fatal  cases  if  attention  were  particularly  directed  to 
the  point.  In  both  these  instances  it  was  exceedingly  well  marked, 
and  in  both  it  entirely  disappeared  when  the  symptoms  abated.  The 
probability  of  such  a  murmur  being  audible  in  cases  of  thrombosis 
of  the  pulmonary  artery,  has  been  recognized  by  one  of  our  highest 
authorities  in  cardiac  disease,  who  actually  observed  it  in  a  non- 
puerperal  case.  In  the  last  edition  of  his  work  on  diseases  of  the 
heart,  "Dr.  "Walshe*  says:  "The  only  physical  condition  connected 
with  the  vessel  itself  would  probably  be  systolic  basic  murmur  fol- 
lowing the  course  of  the  pulmonary  main  trunk  and  of  its  immediate 
divisions  to  the  left  and  right  of  the  sternum.  This  sign  I  most 
certainly  heard  in  an  old  gentleman  whose  life  was  brought  to  a 

1  Clinical  Essays,  p.  224  et  seq. 

2  Walshe,  On  'Diseases  of  the  Heart,  4th  ed.  1873'. 


PUERPERAL    VENOUS    THROMBOSIS    AND    EMBOLISM. 

sudden  close,  in  the  course  of  an  acute  affection,  by  coagulation  in 
the  pulmonary  artery,  and  to  a  moderate  extent  in  the  right  ven- 
tricle." 

Similar  cases  have,  probably,  been  overlooked  or  misinterpreted. 
Many  seem  to  have  been  attributed  to  shock,  in  the  absence  of  a 
better  explanation,  a  condition  to  which  they  bear  no  kind  of  re- 
semblance. 

Causes  of  Death. — The  precise  mode  of  death  in  pulmonary  ob- 
struction, whether  dependent  on  thrombosis  or  embolism,  has  given 
rise  to  considerable  difference  of  opinion.  Yirchow  attributes  it  to 
syncope,1  depending  on  stoppage  of  the  cardiac  contraction.  Panurn,2 
on  the  other  handy  contests  this  view,  maintaining  that  the  heart  con- 
tinues to  beat  even  after  all  signs  of  life  have  ceased.  Certainly 
tumultuous  and  irregular  pulsations  of  the  heart  are  prominent 
symptoms  in  most  of  the  recorded  cases,  and  are  not  reconcilable 
with  the  idea  of  syncope.  Panum's  own  theory  is,  that  death  is  the 
result  of  cerebral  anasmia.  Paget  seems  to  think  that  the  mode  of 
death  is  altogether  peculiar,  in  some  respects  resembling  syncope,  in 
others  anaemia.  Bertin,  who  has  discussed  the  subject  at  great 
length,  attributes  the  fatal  result  purely  to  asphyxia.  The  condition, 
indeed,  is  in  all  respects  similar  to  that  state;  the  oxygenation  of  the 
blood  being  prevented,  not  because  air  cannot  get  to  the  blood,  but 
because  blood  cannot  get  to  the  air.  The  symptoms  also  seem  best 
explained  by  this  theory;  the  intense  dyspnoea,  the  terrible  struggle 
for  air,  the  preservation  of  intelligence,  the  tumultuous  action  of  the 
heart,  are  certainly  not  characteristic  either  of  syncope  or  anasmia. 

Post-mortem  Appearances  of  Glots. — The  anatomical  character  of 
the  clots  seems  to  vary  considerably.  Ball,  by  whom  they  have  been 
most  carefully  described,  believes  that  they  generally  commence  in 
the  smaller  ramifications  of  the  arteries,  extending  backwards 
towards  the  heart,  and  filling  the  vessels  more  or  less  completely. 
Towards  its  cardiac  extremity  the  coagulum  terminates  in  a  rounded 
head,  in  which  respect  it  resembles  those  spontaneously  formed  in 
the  peripheral  veins.  It  is  non-adherent  to  the  coats  of  the  vessels, 
and  the  blood  circulates,  when  it  can  do  so  at  all,  between  it  and  the 
vascular  walls.  Such  clots  are  white,  dense,  and  of  a  homogeneous 
structure,  consisting  of  layers  of  decolorized  fibrine,  firm  at  the  peri- 
phery, where  the  fibrine  has  been  most  recently  deposited,  and  soft- 
ened in  the  centre,  where  amylaceous  or  fatty  degeneration  has 
commenced.  Ball  maintains  that  if  the  coagulum  have  commenced 
in  the  larger  branches  of  the  arteries,  it  must  have  first  begun  in 
the  ventricle,  and  extended  into  them.  According  to  Humphrey, 
the  same  changes  take  place  in  pulmonary  as  in  peripheral  thrombi, 
and  they  may  become  adherent  to  the  walls  of  the  vessels,  or  con- 
verted into  threads  or  bands.  When  the  obstruction  is  due  to  em- 
bolism, provided  the  case  is  a  well-marked  one,  and  the  embolus  of 
some  size,  the  appearances  presented  are  different.  We  have  no 
longer  a  laminated  and  decolorized  coagulum,  with  a  rounded  head, 

1  Gesamm.  Abhandl  ,  1862,  p.  316.  2  Virchow's  Archiv,  1863. 


604  THE    PUERPERAL    STATE. 

similar  to  a  peripheral  thrombus.  The  obstruction  in  this  case 
generally  takes  place  at  the  point  of  bifurcation  of  the  artery,  and 
we  there  meet  with  a  grayish-white  mass,  contrasting  remarkably 
with  the  more  recently  deposited  fibrine  before  and  behind  it.  It  may 
be  that  the  form  of  the  embolus  shows  that  it  has  recently  been 
separated  from  a  clot  elsewhere;  and  in  many  cases  it  has  been  pos- 
sible to  fit  the  travelled  portion  to  the  extremity  of  the  clot  from 
which  it  has  been  broken.  We  may  also,  perhaps,  find  that  the 
embolus  has  undergone  an  amount  of  retrograde  metamorphosis 
corresponding  with  that  of  the  peripheral  thrombus  from  which  we 
suppose  it  to  have  come,  but  differing  from  that  of  the  more  recently 
deposited  fibrine  around  it.  It  must  be  admitted,  however,  that  the 
anatomical  peculiarities  of  the  coagula  will  by  no  means  always 
enable  us  to  trace  them  to  their  true  origin.  In  many  cases  ernboli 
may  escape  detection  from  their  smallness,  or  from  the  quantity  of 
fibrine  surrounding  them. 

Treatment. — But  few  words  need  be  said  as  to  the  treatment  of 
pulmonary  obstruction.  In  a  large  majority  of  cases  the  fatal  result 
so  rapidly  follows  the  appearance  of  the  symptoms,  that  no  time  is 
given  us  even  to  make  an  attempt  to  alleviate  the  patient's  suffer- 
ings. Should  we  meet  with  a  case  not  immediately  fatal,  it  seems 
that  there  are  but  two  indications  of  treatment  affording  the  slightest 
rational  ground  of  hope  : — 

1.  To  keep  the  patient  alive  by  the  administration  of  stimulants — 
brandy,  ether,  ammonia,  and  the  like — to  be  repeated  at  intervals 
corresponding  to  the  intensity  of  the  paroxysms,  and  the  results  pro- 
duced.   In  the  cases  I  have  above  narrated,  in  which  recovery  ensued, 
this  took  the  place  of  all  other  medication.     Possibly  leeches,  or  dry 
cupping  to  the  chest,  might  prove  of  some  service  in  relieving  the 
circulation. 

2.  To  enjoin  the  most  absolute  and  complete  repose.     The  object 
of  this  is  evident.    The  only  chance  for  the  patient  seems  to  be,  that 
the  vital  functions  should  be  carried  on  until  the  coagulum  has  been 
absorbed,  or,  at  least,  until  it  has  been  so  much  lessened  in  size  as  to 
admit  of  blood  passing  it  to  the  lungs.     The  slightest  movements 
may  give  rise  to  a  fatal  paroxysm  of  dyspnoea,  from  the  increased 
supply  of  oxygenated  blood  required.    It  must  not  be  forgotten  that 
in  a  large  proportion  of  cases  death  immediately  followed  some  exer- 
tion in  itself  trivial,  such  as  rising  out  of  bed.     Too  much  attention, 
then,  cannot  be  given  to  tkis  point.    The  patient  should  be  absolutely 
still ;  she  should  be  fed  with  abundance  of  fluid  food,  such  as  milk, 
strong  soups,  and  the  like ;  and  should  on  no  account  be  permitted 
to  raise  herself  in  bed,  or  attempt  the  slightest  muscular  exertion. 
If  we  are  fortunate  enough  to  meet  with  a  case  apparently  tending 
to  recovery,  these  precautions  must  be  carried  on  long  after  the 
severity  of  the  symptoms  has  lessened,  for  a  moment's  imprudence 
may  suffice  to  bring  them  back  in  all  their  original  intensity. 

Bertin,1  indeed,  recommends  a  system  of  treatment  very  different 

1  Op.  cit.  p.  393. 


PUERPERAL    ARTERIAL    THROMBOSIS    AND    EMBOLISM.        605 

from  this.  In  the  vain  hope  that  the  violent  effort  induced  may 
cause  the  displacement  of  the  impacted  embolus  (to  which  alone  he 
attributes  pulmonary  obstruction),  he  recommends  the  administra- 
tion of  emetics.  Few,  I  fancy,  will  be  found  bold  enough  to  attempt 
so  hazardous  a  plan  of  treatment. 

Various  drugs  have  been  suggested  in  these  cases.  Richardson 
recommended  ammonia,  a  deficiency  of  which  he  at  that  time  believed 
to  be  the  chief  cause  of  coagulation.  He  has  since  advised  that 
liquor  ammonias  should  be  given  in  large  doses,  20  minims  every 
hour,  in  the  hope  of  causing  solution  of  the  deposited  fibrine ;  and 
he  has  stated  that  he  has  seen  good  results  from  the  practice.  Others 
advise  the  administration  of  alkalies,  in  the  hope  that  they  may 
favor  absorption.  The  best  that  can  be  said  for  them  is,  that  they 
are  not  likely  to  do  much  harm. 


CHAPTER  VII. 

PUERPEKAL   AETERIAL   THROMBOSIS    AND    EMBOLISM. 

THE  same  condition  of  the  blood  which  so  strongly  predisposes  to 
coagulation  in  the  vessels  through  which  venous  blood  circulates, 
tends  to  similar  results  in  the  arterial  system.  These,  however,  are 
by  no  means  so  common,  and  do  not,  as  a  rule,  lead  to  such  important 
consequences.  The  subject  has  been  but  little  studied,  and  almost 
all  our  knowledge  of  it  is  derived  from  a  very  interesting  essay  by 
Sir  James  Simpson.1  As  I  have  devoted  so  much  space  to  the  con- 
sideration of  venous  thrombosis  and  embolism,  I  shall  but  briefly 
consider  the  effects  of  arterial  obstruction. 

Causes. — In  a  considerable  number  of  recorded  cases  the  obstruc- 
tion has  resulted  from  the  detachment  of  vegetations  deposited  on 
the  cardiac  valves,  the  result  of  endocarditis,  either  produced  by 
antecedent  rheumatism,  or  as  a  complication  of  the  puerperal  state. 
Sometimes  the  obstruction  seems  to  depend  on  some  general  blood 
dyscrasia,  similar  to  that  producing  venous  thrombosis,  or  on  some 
local  change  in  the  artery  itself.  Thus  Simpson  records  a  case  ap- 
parently produced  by  local  arteritis,  which  caused  acute  gangrene  of 
both  lower  extremities,  ending  fatally  in  the  third  week  after  de- 
livery. In  other  cases  it  has  been  attributed  to  coagulation  follow- 
ing spontaneous  laceration  and  corrugation  of  the  internal  coat  of  the 
artery. 

Symptoms. — The  symptoms  of  puerperal  arterial  obstruction  must, 
of  course,  vary  with  the  particular  arteries  affected.  Those,  with 

1  Selected  Obst.  Works,  vol.  i.  p.  523. 


606  THE    PUERPERAL    STATE. 

the  obstruction  of  which  we  are  most  familiar,  are  the  cerebral,  the 
humeral,  and  the  femoral.  The  effects  produced  must  also  be  modi- 
fied by  the  size  of  the  embolus,  and  the  more  or  less  complete  ob- 
struction it  produces.  Thus,  for  example,  if  the  middle  cerebral 
artery  be  blocked  up  entirely,  the  functions  of  those  portions  of  the 
brain  supplied  by  it  will  be  more  or  less  completely  arrested,  and 
hemiplegia  of  the  opposite  side  of  the  body,  followed  by  softening  of 
the  brain-texture,  will  probably  result.  If  the  nervous  symptoms 
be  developed  gradually,  or  increase  in  intensity  after  their  first  ap- 
pearance, it  may  be  that  an  obstruction,  at  first  incomplete,  has  in- 
creased by  the  deposition  of  fibrine  around  it.  So  the  occasional 
sudden  supervention  of  blindness,  with  destruction  of  the  eyeball — 
cases  of  which  are  recorded  by  Simpson — not  improbably  depend  on 
occlusion  of  the  ophthalmic  artery,  the  function  of  the  organ  de- 
pending on  its  supply  through  the  single  artery.  The  effects  of  ob- 
struction of  the  visceral  arteries  in  the  puerperal  state  are  entirely 
unknown  ;  but  it  is  far  from  unlikely  that  further  investigation  may 
prove  them  to  be  of  great  importance.  In  the  extremities  arterial 
obstruction  produces  effects  which  are  well  marked.  They  are  classi- 
fied by  Simpson  under  the  following  heads:  1.  Arrest  of  pulse  beloio 
the  site  of  obstruction. — This  has  been  observed  to  come  on  either 
suddenly  or  gradually,  and  if  the  occlusion  be  in  one  of  the  large 
arterial  trunks,  it  is  a  symptom  which  a  careful  examination  will 
readily  enable  us  to  detect.  2.  Increased  force  of  pulsation  in  the  ar- 
teries above  the  seat  of  obstruction.  3.  Fall  in  the  temperature  of  the 
limb. — This  is  a  symptom  which  is  easily  appreciable  by  the  ther- 
mometer, and,  when  the  main  artery  of  the  limb  is  occluded,  the 
coldness  of  the  extremity  is  well  marked.  4.  Lesions  of  motor  and 
sensory  functions,  paralysis,  neuralgia,  etc.  etc. — Loss  of  power  in  the 
affected  lirnb  is  often  a  prominent  symptom,  and  when  it  comes  on 
suddenly,  and  is  complete,  the  main  artery  will  probably  be  occluded. 
It  may  be  diagnosed  from  paralysis  depending  on  cerebral  or  spinal 
causes  by  the  absence  of  head  symptoms,  by  the  history  of  the  attack, 
and  by  the  presence  of  other  indications  of  arterial  obstruction,  such 
as  loss  of  pulsation  in  the  artery,  fall  of  temperature,  etc.  The  sen- 
sory functions  in  these  cases  are  generally  also  seriously  disturbed, 
not  so  much  by  loss  of  sensation,  as  by  severe  pain  and  neuralgia. 
Sometimes  the  pain  has  been  excessive,  and  occasionally  it  has  been 
the  first  symptom  which  directed  attention  to  the  state  of  the  limb. 
5.  Gangrene  below  or  beyond  the  seat  of  arterial  obstruction. — Several 
interesting  cases  are  recorded,  in  which  gangrene  has  followed  arte- 
rial obstruction.  Generally  speaking  gangrene  will  not  follow 
occlusion  of  the  main  arterial  trunk  of  an  extremity,  as  the  collateral 
circulation  becomes  soon  sufficiently  developed  to  maintain  its  vitality. 
In  many  of  the  cases  either  thrombi  have  obstructed  the  channels  of 
collateral  circulation  as  well,  or  the  veins  of  the  limb  have  also 
been  blocked  up.  When  such  extensive  obstructions  occur  they 
obviously  cannot  be  embolic,  but  must  depend  on  a  local  thrombosis, 
traceable  to  some  general  blood  dyscrasia  depending  on  the  puerperal 
state.  ' 


CAUSES  OF  SUDDEN  DEATH  DURING  LABOR. 

Treatment. — Little  can  be  said  as  to  the  treatment  of  such  cases, 
which  must  vary  with  the  gravity  and  nature  of  the  symptoms  in 
each.  Beyond  absolute  rest  (in  the  hope  of  eventual  absorption  of 
the  thrombus  or  ernbolus),  generous  diet,  attention  to  the  general 
health  of  the  patient,  and  sedative  applications  to  relieve  the  local 
pain,  there  is  little  in  our  power.  Should  gangrene  of  an  extremity 
supervene  in  a  puerperal  patient,  the  case  must  necessarily  be  well- 
nigh  hopeless.  Simpson,  ho\vever.  records  one  instance  in  which 
amputation  was  performed  above  the  line  of  demarcation,  the  patient 
eventually  recovering. 


CHAPTER  VIII. 

OTHER  CAUSES  OF  SUDDEN  DEATH  DURING  LABOR  AND  THE 
PUERPERAL  STATE. 

A  LARGE  number  of  the  cases  in  which  sudden  death  occurs  during 
or  after  delivery  find  their  explanation,  as  I  have  already  pointed 
oat,  in  thrombosis  or  embolism  of  the  heart  and  pulmonary  arteries. 
Probably,  many  cases  of  the  so-called  idiopathic  asphyxia  were  in 
fact  examples  of  this  accident,  the  true  nature  of  which  had  been 
misunderstood.  Besides  these  there  are,  no  doubt,  many  other  con- 
ditions which  may  lead  to  a  suddenly  fatal  result  in  connection  with 
parturition. 

Some  of  these  are  of  an  organic,  others  of  a  functional  nature. 

Organic  Causes. — Among  the  former  may  be  mentioned  cases  in 
which  the  straining  efforts  of 'the  second  stage  of  labor  have  pro- 
duced death  in  patients  suffering  from  some  pre-existent  disease  of 
the  heart.  Rupture  of  that  organ  has  probably  occurred  from  fattv 
degeneration  of  its  walls.  Dehous1  narrates  an  instance  in  which  the 
efforts  of  labor  caused  the  rupture  of  an  aneurism.  Another  case, 
from  interference  with  the  action  of  the  heart  in  a  patient  who  had 
pericardial  effusion,  is  narrated  by  Ramsbotham.  Dr.  Devilliers  re- 
lates an  instance  occurring  in  a  young  woman  during  the  second 
stage  of  labor.  The  heart  was  found  to  be  healthy,  but  the  lungs 
were  intensely  congested,  and  blood  was  extensively  extravasated 
all  through  their  texture.  This  was  probably  caused  by  pulmonary 
congestion  and  apoplexy,  produced  by  the  severe  straining  efforts. 
Many  cases  from  effusion  of  blood  into  the  brain-substance,  or  on  its 
surface,  are  on  record,  no  doubt  in  patients  who,  from  arterial  de- 
generation or  other  causes,  were  predisposed  to  apoplectic  effusions. 
The  so-called  apoplectic  convulsions,  formerly  described  in  most 

1  Dehous,  Sur  les  Morts  subites. 


6C8  THE    PUERPERAL    STATE. 

works  on  obstetrics  as  a  variety  of  puerperal  convulsions,  are  evi- 
dently nothing  more  than  apoplexy  coming  on  during  or  after  labor. 
As  regards  their  pathology  they  do  not  seem  to  differ  from  ordinary 
cases  of  apoplexy  in  the  non-pregnant  condition.  One  example  is 
recorded  of  death  which  was  attributed  to  rupture  of  the  diaphragm 
from  excessive  action  in  the  second  stage. 

Functional  Causes. — Among  the  causes  of  death  which  cannot  be 
traced  to  sojne  distinct  organic  lesion,  may  be  classed  cases  of  syncope, 
shock,  and  exhaustion.  Many  instances  of  this  kind  are  recorded. 
Thus  in  some  women  of  susceptible  nervous  organization,  the  severity 
of  the  suffering  appears  to  bring  on  a  condition,  similar  to  that  pro- 
duced by  excessive  shock  or  exhaustion,  which  has  not  unfrequently 
proved  fatal.  Several  examples  of  this  kind  have  been  cited  by 
McClintock.1  It  is  also  not  unlikely  that  sudden  syncope  sometimes 
produces  a  fatal  result,  during  or  after  labor.  Most  cases  of  death, 
otherwise  inexplicable,  used  to  be  referred  to  this  cause ;  but  accu- 
rate autopsies  were  seldom  made,  and  even  when  they  were — the 
important  effects  of  pulmonary  coagula  being  unknown — it  is  more 
than  probable  that  the  true  cause  of  death  was  overlooked.  It  has 
been  supposed  that  the  sudden  removal  of  pressure  from  the  veins 
of  the  abdomen;  by  the  emptying  of  the  gravid  uterus  after  delivery, 
may  favor  an  increased  afflux  of  blood  into  the  lower  parts  of  the 
body,  and  thus  tend  to  an  ansemic  condition  of  the  brain,  and  the 
production  of  syncope.  However  this  may  be,  the  possibility  of  its 
occurrence,  and  its  manifest  danger  in  a  recently  delivered  woman, 
are  sufficient  reasons  for  enforcing  the  recumbent  position  after  labor 
is  over.  In  some  of  the  cases  the  syncope  was  evidently  produced 
by  the  patient's  suddenly  sitting  upright. 

Death  from  Air  in  the  Veins. — Some  cases  of  sudden  death  imme- 
diately after  labor  seem  to  be  due  to  the  entrance  of  air  into  the 
veins.  Six  examples  are  cited  by  McClintock  which  were  probably 
due  to  this  cause.  La  Chapelle  relates  two.  An  interesting  case  is 
related  by  M.  Lionet.2  In  this  the  patient  died  five  and  a  half  hours 
after  an  easy  and  natural  labor,  the  chief  symptoms  being  extreme 
pallor,  efforts  at  vomiting,  and  dyspnoea.  Air  was  found  in  the  heart 
and  in  the  arachnoid  veins.  There  can  be  no  question  that  the  ute- 
rine sinuses  after  delivery  are  nearly  as  well  adapted  as  the  veins  of 
the  neck  for  allowing  the  entrance  of  air.  They  are  firmly  attached 
to  the  muscular  walls  of  the  uterus,  so  that  they  gape  open  when 
that  organ  is  relaxed,  and  it  is  easy  to  understand  how  air  might 
enter.  Indeed,  in  the  post-mortem  examination  in  one  of  the  cases 
occurring  in  the  practice  of  Mme.  La  Chapelle,  it  is  stated  that  "the 
uterine  sinuses  opened  in  the  interior  of  the  uterus  by  large  orifices 
(one  line  and  a  half  in  diameter),  through  which  air  could  readily  be 
blown  as  far  as  the  iliac  veins,  and  vice  versa.'1'1  The  condition  of 
the  uterus  after  delivery  also  enables  the  air  to  have  ready  access  to 
the  mouths  of  the  sinuses,  for  the  alternate  relaxation  and  contrac- 
tion of  the  uterus,  occurring  after  the  placenta  is  expelled,  would 

1  Union  Medic.,  1853.  *  Dehous,  op.  cit.  p.  58. 


PERIPHERAL    VENOUS    THROMBOSIS,    ETC.  609 

tend  to  draw  in  the  air  as  by  a  suction  pump.  Hence,  an  additional 
reason  for  insisting  on  firm  contraction  of  the  uterus,  as  this  will 
lessen  the  risk  of  this  accident. 

Cause  of  Death  in  such  Cases. — The  precise  mechanism  of  death 
from  air  in  the  veins  has  been  a  subject  of  dispute  among  patholo- 
gists.  By  Bichat, '  it  was  referred  to  anaemia  and  syncope  from  want 
of  blood  in  the  vessels  of  the  brain,  which  are  occupied  by  air ; 
Nysten2  attributed  it  to  distension  of  the  cavities  of  the  heart  by 
rarefied  air,  producing  paralysis  of  its  walls;  Geroy  to  a  stoppage  of 
the  pulmonary  circulation,  arid  consequent  want  of  proper  blood- 
supply  to  the  left  heart;  while  Leroy  d'Etoilles  thought  it  might 
depend  on  any  of  these  causes,  or  a  combination  of  all  of  them. 
These,  and  many  other  hypotheses  on  the  subject,  have  been  ad- 
vanced, to  all  of  which  serious  objection  could  be  raised.  The  most 
recent  theory  is  one  maintained  by  Virchow  and  Oppolzer,3  and  more 
recently  by  Feltz,  which  attributes  the  fatal  results  to  impaction  of 
the  air-globules  in  the  lesser  divisions  of  the  pulmonary  arteries, 
where  they  form  gaseous  emboli,  and  cause  death  exactly  in  the  same 
way  as  when  the  obstruction  depends  on  a  fibrinous  embolus.  The 
symptoms  observed  in  fatal  cases  closely  correspond  to  those  of  pul- 
monary obstruction,  and  it  is  not  unlikely  that  some  cases,  attributed 
to  other  causes,  may  really  depend  on  the  entrance  of  air  through 
the  uterine  sinuses.  Such,  for  example,  was  most  probably  the 
explanation  of  a  case  referred  to  by  Dr.  Grail  y  Hewitt  in  a  discussion 
at  the  Obstetrical  Society.4  Death  occurred  shortly  after  the  removal 
of  an  adherent  placenta,  during  which,  no  doubt,  air  could  readily 
enter  the  uterine  cavity.  The  symptoms,  viz.,  "severe  pain  in  the 
cardiac  region,  distress  as  regards  respiration,  and  pulselessness,"  are 
identical  with  those  of  pulmonary  obstruction.  Dr.  Hewitt  refers 
the  death  to  shock,  which  certainly  does  not  generally  produce  such 
phenomena. 


CHAPTER  IX. 

PERIPHERAL  VENOUS  THROMBOSIS — (SYN. :  CRURAL  PHLEBITIS — 
PHLEGM  ASIA  DOLENS — ANASARCA  SEROSA — (EDEMA  LACTEUM — • 
WHITE  LEG,  ETC.). 

WE  now  come  to  discuss  the  symptoms  and  pathology  of  the  con- 
ditions associated  with  the  formation  of  thrombi  in  the  peripheral 
venous  system,  or  rather  in  the  veins  of  the  lower  extremities,  since 

1  Recherches  sur  la  Vie  et  la  Mort,  1853. 

2  Nysten,  Recherches  de  Phys.  et  Chem.  Path.,  1811. 

8  Casuistics  des  Embolie ;  AViener  Med.  Woch  ,  1863.  Des  Embolies  Capillaires, 
1868.  Op.  cit.,  p.  115. 

4  Obstet.  Trans.,  vol.  x.  p.  28. 


610  THE    PUERPERAL    STATE. 

too  little  is  known  of  their  occurrence  in  other  parts  to  enable  us  to 
say  anything  on  the  subject. 

The  most  important  of  these  is  the  well-known  disease  which, 
under  the  name  of  phlegmasia  dolens,  has  attracted  much  attention, 
and  given  rise  to  numerous  theories  as  to  its  nature  and  pathology. 
In  describing  it  as  a  local  manifestation  of  a  general  blood-dyscrasia, 
and  not  as  an  essential  local  disease,  I  am  making  an  assumption  as 
to  its  pathology,  that  many  eminent  authorities  would  not  consider 
justifiable.  I  have,  however,  already  stated  some  of  the  reasons  for 
so  doing,  and  I  shall  shortly  hope  to  show  that  this  view  is  not 
incompatible  with  the  most  probable  explanation  of  the  peculiar 
state  of  the  affected  limb. 

Symptoms. — The  first  symptom  which  usually  attracts  attention  is 
severe  pain  in  some  part  of  the  limb  that  is  about  to  be  affected. 
The  character  of  the  pain  varies  in  different  cases.  In  some  it  is 
extremely  acute,  and  is  most  felt  in  the  neighborhood  of,  and  along 
the  course  of  the  chief  venous  trunks.  It  may  begin  in  the  groin  or 
hip,  and  extend  downwards ;  or  it  may  commence  in  the  calf,  and 
proceed  upwards  towards  the  pelvis.  The  pain  abates  somewhat 
after  swelling  of  the  limb  (which  generally  begins  within  twenty- 
four  hours),  but  it  is  always  a  distressing  symptom,  and  continues  as 
long  as  the  acute  stage  x>f  the  disease  lasts.  The  restlessness,  want 
of  sleep,  and  suffering  which  it  produces  are  sometimes  excessive. 
Coincident  with  the  pain,  and  sometimes  preceding  it,  more  or  less 
malaise  is  experienced.  The  patient  may  for  a  day  or  two  be  rest- 
less, irritable,  and  out  of  sorts,  without  any  very  definite  cause; 
or  the  disease  may  be  ushered  in  by  a  distinct  rigor.  Generally  there 
is  constitutional  disturbance,  varying  with  the  intensity  of  the  case. 
The  pulse  is  rapid  and  weak,  120  or  thereabouts;  the  temperature 
elevated  from  101°  to  102°,  with  an  evening  exacerbation.  The  pa- 
tient is  thirsty;  the  tongue  glazed,  or  white  and  loaded;  the  bowels 
constipated.  In  some  few  cases,  when  the  local  affection  is  slight, 
none  of  these  constitutional  symptoms  are  observed. 

Condition  of  the  Affected  Limb. — The  characteristic  swelling  rapidly 
follows  the  commencement  of  the  symptoms.  It  generally  begins  in 
the  groin,  from  whence  it  extends  downwards.  It  may  be  limited  to 
the  thigh ;  or  the  whole  limb,  even  to  the  feet,  may  be  implicated. 
More  rarely  it  commences  in  the  calf  of  the  leg,  extending  upwards 
to  the  thigh,  and  downwards  to  the  feet.  The  affected  parts  have  a 
peculiar  appearance,  which  is  pathognomonic  of  the  disease.  They 
are  hard,  tense,  and  brawny  ;  of  a  shiny,  white  color ;  and  not  yield- 
ing on  pressure,  except  towards  the  beginning  and  end  of  the  illness. 
The  appearances  presented  are  quite  different  from  those  of  ordinary 
oedema.  When  the  whole  thigh  is  affected  the  limb  is  enormously 
increased  in  size.  Frequently  the  venous  trunks,  especially  the 
femoral  and  popliteal  veins,  are  felt  obstructed  with  coagula,  and 
rolling  under  the  finger.  They  are  painful  when  handled,  and  in 
their  course  more  or  less  redness  is  occasionally  observed.  Either 
leg  may  be  attacked,  but  the  left  more  frequently  than  the  right. 
There  is  a  marked  tendency  for  the  disease  to  spread,  and  we  often 


PUERPERAL    VENOUS    THROMBOSIS,    ETC.  Gil 

find,  in  a  case  which  is  progressing  apparently  well,  a  rise  of  tem- 
perature and  an  accession  of  febrile  symptoms,  followed  by  the  swell- 
ing of  the  other  limb. 

Progress  of  the  Disease. — After  the  acute  stage  has  lasted  from  a 
week  to  a  fortnight,  the  constitutional  disturbance  becomes  less 
marked,  the  pulse  and  temperature  fall,  the  pain  abates,  and  the 
sleeplessness  and  restlessness  are  less.  The  swelling  and  tension  of 
the  limb  now  begin  to  diminish,  and  absorption  commences.  This  is 
invariably  a  slow  process.  It  is  always  many  weeks  before  the  effu- 
sion has  disappeared,  and  it  may  be  many  months.  The  limb  re- 
tains for  a  length  of  time  the  peculiar  wooden  feeling,  as  Dr.  Churchill 
terms  it.  Any  imprudence,  such  as  a  too  early  attempt  at  walking, 
may  bring  on  a  relapse  and  fresh  swelling  of  the  limb.  This  gradual 
recovery  is  by  far  the  most  common  termination  of  the  disease.  In 
some  rare  cases  suppuration  may  take  place,  either  in  the  subcuta- 
neous cellular  tissue,  the  lymphatic  glands,  or  even  in  the  joints,  and 
death  may  result  from  exhaustion.  The  possibility  of  pulmonary 
obstruction  and  sudden  death  from  separation  of  an  embolus  have 
already  been  pointed  out,  and  the  fact  that  this  lamentable  occurrence 
has  generally  followed  some  undue  exertion  should  be  borne  in  mind, 
as  a  guide  in  the  management  of  our  patient. 

Period  of  Commencement. — The  disease  usually  begins  within  a 
short  time  after  delivery,  rarely  after  the  second  week.  In  22  cases 
tabulated  by  Dr.  Robert  Lee,  7  were  attacked  between  the  fourth  and 
twelfth  days,  and  14  after  the  second  week.  Some  cases  have  been 
described  as  commencing  even  months  after  delivery.  It  is  question- 
able if  these  can  be  classed  as  puerperal,  for  it  must  not  be  forgotten 
that  phlegmasia  dolens  is  by  no  means  necessarily  a  puerperal  disease. 
There  are  many  other  conditions  which  may  give  rise  to  it,  all  of 
them,  however,  such  as  produce  a  septic  and  hyperinosed  state  of  the 
blood,  such  as  malignant  disease,  dysentery,  phthisis,  and  the  like. 
My  own  experience  would  lead  me  to  think  that  cases  of  this  kind 
are  much  more  common  than  is 'generally  believed. 

History  and  Pathology. — The  disease  has  long  attracted  the  atten- 
tion of  the  profession.  Passing  over  more  or  less  obscure  notices  by 
Hippocrates,  De  Castro,  and  others,  we  find  the  first  clear  account  in 
the  writings  of  Mauriceau,  who  not  only  gave  a  very  accurate  de- 
scription of  its  symptoms,  but  made  a  guess  at  its  pathology,  which 
was  certainly  more  happy  than  the  speculations  of  his  successors ;  it 
is,  he  says,  caused,  "  by  a  reflux  on  the  parts  of  certain  humors 
which  ought  to  have  been  evacuated  by  the  lochia."  Puzos  ascribed 
it  to  the  arrest  of  the  secretion  of  milk,  and  its  extravasation  in  the 
affected  limb.  This  theory,  adopted  by  Levret  and  many  subsequent 
writers,  took  a  strong  hold  on  both  professional  and  public  opinion, 
and  to  it  we  owe  many  of  the  names  by  which  the  disease  is  known 
to  this  day,  such  as  oedema  lacteum,  milk  leg,  etc.  In  1784  Mr. 
"White,  of  Manchester,  attributed  it  to  some  morbid  condition  of 
the  lymphatic  glands  and  vessels  of  the  affected  parts ;  and  this,  or 
some  analogous  theory,  such  as  that  of  rupture  of  the  lymphatics 
crossing  the  pelvic  brim,  as  maintained  by  Tyre,  of  Gloucester,  or 


612  THE    PUERPERAL    STATE. 

general  inflammation  of  the  absorbents  as  held  by  Dr.  Ferriar,  was 
generally  adopted. 

Phklitic  Theory. — It  was  not  until  the  year  1823  that  attention  was 
drawn  to  the  condition  of  the  veins.  To  Bouillaud  belongs  the  un- 
doubted merit  of  first  pointing  out  that  the  veins  of  the  aft'ected  limb 
were  blocked  up  by  coagula,  although  the  fact  had  been  previously 
observed  by  Dr.  Davis,  of  University  College.  Dr.  Davis  made  dissec- 
tions of  the  veins  in  a  fatal  case,  and  found,  as  Bouillaud  had  done, 
that  they  were  filled  with  coagula,  which  he  assumed  to  be  the 
results  of  inflammation  of  their  coats;  hence  the  name  of  "crural 
phkliitis"  which  has  been  extensively  adopted  instead  of  phlegrnasia 
dolens.  Dr.  Eobert  Lee  did  much  to  favor  this  view,  and  finding 
that  thrombi  were  present  in  the  iliac  and  uterine,  as  well  as  in  the 
femoral,  veins,  he  concluded  that  the  phlebitis  commenced  in  the 
uterine  branches  of  the  hypogastric  veins,  and  extended  downwards 
to  the  femorals.  He  pointed  out  that  phlegmasia  dolens  was  not 
limited  to  the  puerperal  state ;  but  that  when  it  did  occur  independ- 
ently of  it,  other  causes  of  uterine  phlebitis  were  present,  such  as 
cancer  of  the  os  and  cervix  uteri.  The  inflammatory  theory  was 
pretty  generally  received,  and  even  now  is  considered  by  many  to  be 
a  sufficient  explanation  of  the  disease.  Indeed  the  fact  that  more  or 
less  thrombus  was  always  present  could  not  be  denied,  and  on  the 
supposition  that  thrombus  could  only  be  caused  by  phlebitis,  as  was 
long  supposed  to  be  the  case,  the  inflammatory  theory  was  the  natural 
one.  Before  long,  however,  pathologists  pointed  out  that  thrombosis 
was  by  no  means  necessarily,  or  even  generally,  the  result  of  inflam- 
mation of  the  vessels  in  which  the  clot  was  contained,  but  that  the 
inflammation  was  more  generally  the  result  of  the  coagulum. 

Theory  of  its  Dependence  on  Septic  Causes. — The  late  Dr.  Mackenzie 
took  a  prominent  part  in  opposing  the  phlebitic  theory.  He  proved, 
by  numerous  experiments  in  the  lower  animals,  that  inflammation 
is  not  sufficient  of  itself  to  produce  the  extensive  thrombi  which  are 
found  to  exist,  and  that  inflammation  originating  in  one  part  of  a 
vein  is  not  apt  to  spread  along  its  canal,  as  the  phlebitic  theory 
assumes.  His  conclusion  is,  that  the  origin  of  the  disease  is  rather 
to  be  sought  in  some  septic  or  altered  condition  of  the  blood,  pro- 
ducing coagulation  in  the  veins.  Dr.  Tyler  Smith1  pointed  out  an 
occasional  analogy  between  the  causes  of  phlegmasia  dolens  and  puer- 
peral fever,  evidently  recognizing  the  dependence  of  the  former  on 
blood  dyscrasia.  "  I  believe,"  he  says,  "  that  contagion  and  infection 
play  a  very  important  part  in  the  production  of  the  disease.  I  look 
on  a  woman  attacked  with  phlegmasia  dolens  as  having  made  a 
fortunate  escape  from  the  greater  dangers  of  diffuse  phlebitis  or 
puerperal  fever."  In  illustration  of  this  he  narrates  the  following 
instructive  history  :  "  A  short  time  ago  a  friend  of  mine  had  been  in 
close  attendance  on  a  patient  dying  of  erysipelatous  sore-throat  with 
sloughing,  and  was  himself  affected  with  sore-throat.  Under  these 
circumstances,  he  attended,  within  the  space  of  twenty-four  hours, 

1  Tyler  Smith,  Manual  of  Obstetrics,  p.  538. 


PUERPERAL    VENOUS    THROMBOSIS,    ETC.  013 

three  ladies  in  their  confinements,  all  of  whom  were  attacked  with 
phlegmasia  dolens." 

View  of  Tilbury  Fox. — The  latest  important  contribution  to  the 
pathology  of  the  disease  is  contained  in  two  papers  by  Dr.  Tilbury 
Fox,  published  in  the  second  volume  of  the  "  Obstetrical  Transac- 
tions." He  maintains  that  something  beyond  the  mere  presence  of 
coagula  in  the  veins  is  required  to  produce  the  phenomena  of  the 
disease,  although  he  admits  that  to  be  an  important,  and  even  an 
essential,  part  of  pathological  changes  present.  The  thrombi  he  be- 
lieves to  be  produced  either  by  extrinsic  or  intrinsic  causes :  the 
former  comprising  all  cases  of  pressure  by  tumor  or  the  like ;  the 
latter,  and  the  most  important,  being  divisible  into  the  heads  of — • 

1.  True  inflammatory  changes  in  the  vessels,  as  seen  in  the  epi- 
demic form  of  the  disease. 

2.  Simple  thrombus,  produced  by  rapid   absorption   of  morbid 
fluid. 

3.  Virus  action  and  thrombus  conjoined,  the  plegmasia  dolens 
itself  being  the  result  of  simple  thrombus,  and  not  produced  by  dis- 
eased (inflamed)  coats  of  vessels ;  the  general  symptoms  the  result  of 
the  general  blood-state ;  the  virus  present. 

He  further  points  out  that  the  peculiar  swelling  of  the  limbs  can- 
not be  explained  by  the  mere  presence  of  oedema,  from  which  it  is 
essentially  different.  The  white  appearance  of  the  skin,  the  severe 
neuralgic  pain,  and  the  persistent  numbness  indicating  that  the  whole 
of  the  cutaneous  textures,  the  cutis  vera  and  even  the  epithelial 
layer,  are  infiltrated  with  fibrinous  deposit.  He  concludes,  there- 
fore, that  the  swelling  is  the  result  of  oedema  plus  something  else ; 
that  something  being  obstruction  of  the  lymphatics,  by  which  the 
absorption  of  effused  serum  is  prevented.  The  efficient  cause  which 
produces  these  changes  he  believes  to  be,  in  the  majority  of  cases,  a 
septic  action  originating  in  the  uterus,  producing  a  condition  similar 
to  that  in  which  phlegmasia  dolens  arises  in  the  non-puerperal  state. 

There  is  no  doubt  much  force  in  Dr.  Fox's  arguments,  and  it  may, 
I  think,  be  conceded  that  obstruction  of  the  veins  per  se  is  not  suffi- 
cient to  produce  the  peculiar  appearance  of  the  limb.  It  is,  more- 
over, certain  that  phlebitis  alone  is  also  an  insufficient  explanation 
not  only  of  the  symptoms,  but  even  of  the  presence  of  thrombi  so 
extensive  as  those  that  are  found.  The  view  which  traces  the 
disease  solely  to  inflammation  or  obstruction  of  lymphatics  is  purely 
theoretical,  has  no  basis  of  facts  to  support  it,  and  finds,  nowadays, 
no  supporters.  The  experiments  of  Mackenzie  and  Lee,  as  well  as 
the  vastly  increased  knowledge  of  the  causes  of  thrombosis  which 
the  researches  of  modern  pathologists  have  given  us,  seem  to  point 
strongly  to  the  view  already  stated,  that  the  disease  can  only  be 
explained  by  a  general  blood  dyscrasia,  depending  on  the  puerperal 
state.  It  by  no  means  follows  that  we  are  to  consider  Dr.  Fox's 
speculations  as  incorrect.  It  is  far  from  improbable  that  the  lym- 
phatic vessels  are  implicated  in  the  production  of  the  peculiar  swell- 
ing, only  we  are  not  as  yet  in  a  position  to  prove  it.  There  is  no 
inherent  improbability  in  the  supposition  that  the  same  morbid 


614  THE    PUERPERAL    STATE. 

state  of  the  blood  which  produces  thrombosis  in  the  veins,  may  also 
give  rise  to  such  an  amount  of  irritation  in  the  lymphatics  as  may 
interfere  with  their  functions,  and  even  obstruct  them  altogether. 
The  essential  and  all-important  point  in  the  pathology  of  the  disease, 
however,  seems  undoubtedly  to  be  thrombosis  in  the  veins;  and  the 
probability  of  there  being  some  as  yet  undetermined  pathological 
changes  in  addition  to  this,  by  no  means  militates  against  the  view 
I  have  taken  of  the  intimate  connection  of  the  disease  with  other 
results  of  thrombosis  in  more  distant  vessels. 

Changes  Occurring  in  the  Thrombi. — The  changes  which  take  place 
in  the  thrombi  all  tend  to  their  ultimate  absorption.  These  have 
been  described  by  various  authors  as  leading  to  organization  or 
suppuration.  It  is  probable,  however,  that  the  appearances  which 
have  led  to  such  a  supposition  are  fallacious,  and  that  they  are  really 
due  to  retrograde  metamorphosis  of  the  fibrine,  generally  of  an  amy- 
laceous or  fatty  character. 

Detachment  of  Emboli. — The  peculiarities  of  a  clot  that  most  favor 
detachment  of  an  ernbolus  are  such  a  shape  as  admits  of  a  portion 
floating  freely  in  the  blood  current,  by  the  force  of  which  it  is 
detached  and  carried  to  its  ultimate  destination.  When  the  accident 
has  occurred,  it  is  often  possible  to  recognize  the  peripheral  thrombus 
from  which  the  embolus  has  separated,  by  the  fact  of  its  terminal 
extremity  presenting  a  freshly  fractured  end,  instead  of  the  rounded 
head  natural  to  it.  Such  detachment  is  unlikely  to  occur,  even 
when  favored  by  the  shape  of  the  clot,  unless  sufficient  time  have 
elapsed  after  its  formation  to  admit  of  its  softening  and  becoming 
brittle.  The  curious  fact  I  have  before  mentioned,  of  true  puerperal 
embolism  occurring,  in  the  large  majority  of  cases,  only  after  the 
nineteenth  day  from  delivery,  finds  a  ready  explanation  in  this 
theory,  which  it  remarkably  corroborates. 

Treatment. — On  the  supposition  that  phlegmasia  dolens  was  the 
result  of  inflammation  of  the  veins  of  the  affected  limb,  an  antiphlo- 
gistic course  of  treatment  was  naturally  adopted.  Accordingly, 
most  writers  on  the  subject  recommend  depletion,  generally  by  the 
application  of  leeches,  along  the  course  of  the  affected  vessels.  We 
are  told  that  if  the  pain  continue  the  leeches  should  be  applied  a 
second,  or  even  a  third  time.  If  we  admit  the  septic  origin  of  the 
disease  we  must,  I  think,  see  the  impropriety  of  such  a  practice. 
The  fact  that  it  occurs,  in  a  large  majority  of  cases,  in  patients  of  a 
weakly  and  debilitated  constitution,  often  in  women  who  have 
already  suffered  from  hemorrhage,  is  a  further  reason  for  not  adopt- 
ing this  routine  custom.  If  local  loss  of  blood  be  used  at  all,  it  should 
be  strictly  limited  to  cases  in  which  there  is  much  tenderness  and 
redness  along  the  course  of  the  veins,  and  then  only  in  patients  of 
plethoric  habit  and  strong  constitution ;  cases  of  this  kind  will  form 
a  very  small  minority  of  those  coming  under  our  observation. 

Over-active  Treatment  Unadvisable. — What  has  been  said  of  the 
pathology  of  the  affection  tends  to  the  conclusion  that  active  treat- 
ment of  any  kind,  in  the  hope  of  curing  the  disease,  is  likely  to  be 
useless.  Our  chief  reliance  must  be  on  time  and  perfect  rest,  in 


PUERPERAL    VEXOUS    THROMBOSIS,    ETC.  615 

order  to  admit  of  the  thrombi  and  the  secondary  effusion  being 
absorbed;  while  we  relieve  the  pain  and  other  prominent  symptoms, 
and  support  the  strength  and  improve  the  constitution  of  the  patient. 

Relief  of  Pain,  etc. — The  constant  application  of  heat  and  moisture 
to  the  affected  limb  will  do  much  to  lessen  the  tension  and  pain. 
Wrapping  the  entire  limb  in  linseed-meal  poultices,  frequently 
changed,  is  one  of  the  best  means  of  meeting  this  indication.  If,  as 
is  sometimes  the  case,  the  weight  of  the  poultices  be  too  great  to  be 
readily  borne,  we  may  substitute  warm  flannel  stupes,  covered  with 
oiled  silk.  Local  anodyne  applications  afford  much  relief,  and  may 
be  advantageously  used  along  with  the  poultices  and  stupes,  either 
.by  sprinkling  their  surface  freely  with  laudanum,  or  chloroform  and 
belladonna  liniment,  or  by  soaking  the  flannels  in  poppy-head  fomen- 
tation. It  is  needless  to  say  that  the  most  absolute  rest  in  bed  should 
be  enjoined,  even  in  slight  cases,  and  that  the  limb  should  be  effectu- 
ally guarded  from  undue  pressure  b}^  a  cradle  or  some  similar  con- 
trivance. Local  counter-irritation  has  been  strongly  recommended, 
and  frequent  blisters  have  been  considered  by  some  to  be  almost 
specific.  I  should  myself  hesitate  to  use  blisters,  as  they  would 
certainly  not  be  soothing  applications,  and  one  hardly  sees  how  they 
can  be  of  much  service  in  hastening  the  absorption  of  the  effusion. 

Constitutional  Treatment. — During  the  acute  stage  of  the  disease 
the  constitutional  treatment  must  be  regulated  by  the  condition  of 
the  patient.  Light,  but  nutritious  diet,  must  be  administered  in 
abundance,  such  as  milk,  beef-tea,  and  soups.  Should  there  be  much 
debility,  stimulants  in  moderation  may  prove  of  service.  With 
regard  to  medicines,  we  shall  probably  find  benefit  from  such  as  are 
calculated  to  improve  the  condition  of  the  blood  and  the  general 
health  of  the  patient.  Chlorate  of  potash,  with  dilute  hydrochloric 
acid,  quinine,  either  alone  or  in  combination  with  sesquicarbonate  of 
ammonia,  the  tincture  of  the  perchloride  of  iron,  are  the  drugs  that 
are  most  likely  to  prove  of  service.  Alkalies  and  other  medicines, 
which  have  been  recommended  in  the  hope  of  hastening  the  absorp- 
tion of  coagula,  must  be  considered  as  altogether  useless.  Pain  must 
be  relieved  and  sleep  produced  by  the  judicious  use  of  anodynes, 
such  as  Dover's  powder,  the  subcutaneous  injection  of  morphia,  or 
chloral.  Generally  no  form  answers  so  well  as  the  hypodermic  in- 
jection of  morphia. 

Subsequent  Local  Treatment. — When  the  acute  symptoms  have 
abated,  and  the  temperature  has  fallen,  the  poultices  and  stupes  may 
be  discontinued,  and  the  limb  swathed  in  a  flannel  roller  from  the 
toes  upwards.  The  equable  pressure  and  support  thus  afforded  ma- 
terially aid  the  absorption  of  the  effusion,  and  tend  to  diminish  the 
size  of  the  limb.  At  a  still  later  stage  very  gentle  inunctions  of 
weak  iodine  ointment  may  be  used  with  advantage  once  a  day  before 
the  roller  is  applied.  Shampooing  and  friction  of  the  limb,  generally 
recommended  for  the  purpose  of  hastening  absorption,  should  be 
carefully  avoided,  on  account  of  the  possible  risk  of  detaching  a 
portion  of  the  coagulum,  and  producing  embolism.  This  is  no 
merely  imaginary  danger,  as  the  following  fact  narrated  by  Trousseau 


610  THE    PUERPERAL    STATE. 

proves.  "A  plilegmasia  alba  dolens  had  appeared  on  the  left  side  in 
a  young  woman  suffering  from  peri-uterine  phlegmon.  The  pain 
having  ceased,  a  thickened  venous  trunk  was  felt  on  the  upper  and 
internal  part  of  the  thigh.  Rather  strong  pressure  was  being  made, 
when  M.  Demarquay  felt  something  yield  under  his  fingers.  A  few 
minutes  afterwards  the  patient  was  attacked  with  dreadful  palpita- 
tion, tumultuous  cardiac  action,  and  extreme  pallor,  and  death  was 
believed  to  be  imminent.  After  some  hours,  however,  the  oppression 
ceased,  and  the  patient  eventually  recovered.  A  slightly  attached 
coagulum  must  have  become  separated,  and  conveyed  to  the  heart 
or  pulmonary  artery."1  Warm  douches  of  water,  of  salt  water  if  it 
can  be  obtained,  may  be  advantageously  used  in  the  later  stages  of 
the  disease,  and  they  may  be  applied  night  and  morning,  the  limb 
being  bandaged  in  the  interval.  The  occasional  use  of  the  electric 
current  is  said  to  promote  absorption,  and  would  seem  likely  to  be  a 
serviceable  remedy. 

Change  of  Air,  etc. — When  the  patient  is  well  enough  to  be  moved, 
a  change  of  air  to  the  seaside  will  be  of  value.  Great  caution,  how- 
ever, should  be  recommended  in  using  the  limb,  and  it  is  far  better 
not  to  run  the  risk  of  a  relapse  by  any  undue  haste  in  this  respect. 
It  is  well  to  warn  the  patient  and  her  friends,  that  a  considerable 
time  must  of  necessity  elapse,  before  the  local  signs  of  the  disease 
have  completely  disappeared. 


CHAPTER  X. 

PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS. 

FROM  the  earliest  time  the  occurrence  after  parturition  of  severe 
forms  of  inflammatory  disease  in  and  about  the  pelvis,  frequently 
ending  in  suppuration,  has  been  well  known.  It  i?  only  of  late  years, 
however,  that  these  diseases  have  been  made  the  subject  of  accurate 
clinical  and  pathological  investigation,  and  that  their  true  nature  has 
begun  to  be  understood.  Nor  is  our  knowledge  of  them  as  yet  by 
any  means  complete.  They  merit  careful  study  on  the  part  of  the 
accoucheur,  ior  they  give  rise  to  some  of  the  most  severe  and  pro- 
tracted illnesses  from  which  puerperal  patients  suffer.  They  are 
often  obscure  in  their  origin  and  apt  to  be  overlooked,  and  they  not 
rarely  leave  behind  them  lasting  mischief. 

These  diseases  are  not  limited  to  the  puerperal  state.  On  the  con- 
trary, many  of  the  severest  cases  arise  from  causes  altogether  uncon- 
nected with  child-bearing.  These  will  not  be  now  considered,  and 

1  Trousseau,  Clinique  de  1'Hotel-Dieu  in  Gaz.  des  Hop.,  1860,  p.  577. 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  617 

this  chapter  deals  solely  with  such  forms  as  may  be  directly  traced 
to  child-birth. 

Two  Distinct  Forms. — Recent  researches  have  demonstrated  that 
there  are  two  distinct  varieties  of  inflammatory  disease  met  with 
after  labor,  which  differ  materially  from  each  other  in  many  respects. 
In  one  of  these,  the  inflammation  effects  chiefly  the  connective  tissue 
surrounding  the  generative  organs  contained  within  the  pelvis,  or 
extends  up  from  it  beneath  the  peritoneum,  and  into  the  iliac  fossre. 
In  the  other,  it  attacks  that  portion  of  the  peritoneum  which  covers 
the  pelvic  viscera,  and  is  limited  to  it. 

So  much  is  admitted  by  all  writers,  but  great  obscurity  in  descrip- 
tion, and  consequent  difficulty  in  understanding  satisfactorily  the 
nature  of  these  affections,  have  resulted  from  the  variety  of  nomen- 
clature which  different  authors  have  adopted. 

Thus  the  former  disease  has  been  variously  described  as  pelvic 
cellulitis,  peri-uterine  phlegmon,  para-metritis,  or  pelvic  abscess, 
while  the  latter  is  not  unfrequently  called  peri-metritis,  as  contra- 
distinguished from  para-metritis.  The  use  of  the  prefix  para  or  peri, 
to  distinguish  the  cellular  or  peritoneal  variety  of  inflammation, 
originally  suggested  by  Virchow,  has  been  pretty  generally  adopted 
in  Germany,  and  has  been  strongly  advocated  in  this  country  by 
Matthews  Duncan.  It  has  never,  however,  found  much  favor  with 
English  writers,  and  the  similarity  of  the  two  names  is  so  great  as  to 
lead  to  confusion.  I  have,  therefore,  selected  the  terms  "pelvic  peri- 
tonitis" and  "pelvic  cellulitis"  as  conveying  in  themselves  a  fairly 
accurate  notion  of  the  tissues  mainly  involved. 

Importance  of  Distinguishing  the  Two  Glasses  of  Cases. — The  im- 
portant fact  to  remember  is  that  there  exist  two  distinct  varieties  of 
inflammatory  disease,  presenting  many  similarities  in  their  course, 
symptoms,  and  results,  often  occurring  simultaneously,  but  in  the 
main  distinct  in  their  pathology,  and  capable  of  being  differentiated. 
Thomas  compares  them — and,  as  serving  to  fix  the  facts  on  the 
memory,  the  illustration  is  a  good  one — to  pleurisy  and  pneumonia. 
"Like  them,"  he  says,  "they  are  separate  and  distinct,  like  them 
affect  different  kinds  of  structure,  and  like  them  they  generally  com- 
plicate each  other."  It  might,  therefore,  be  advisable,  as  most 
writers  on  the  disease  occurring  in  the  non-puerperal  state  have 
done,  to  treat  of  them  in  two  separate  chapters.  There  is,  however, 
more  difficulty  in  distinguishing  them  as  puerperal  than  as  non-puer- 
peral affections,  for  which  reason,  as  well  as  for  the  sake  of  brevity, 
I  think  it  better  to  consider  them  together,  pointing  out,  as  I  pro- 
ceed, the  distinctive  peculiarities  of  each. 

Seat  of  Disease. — When  attention  was  first  directed  to  this  class  of 
diseases,  the  pelvic  cellular  tissue  was  believed  to  be  the  only  struc- 
ture affected.  This  was  the  view  maintained  by  Nonat,  Simpson, 
and  many  modern  writers.  Attention  was  first  prominently  directed 
to  the  importance  of  localized  inflammation  of  the  peritoneum,  and 
to  the  fact  that  many  of  the  supposed  cases  of  cellulitis  were  really 
peritonitic,  by  Bernutz.  There  can  be  no  doubt  that  he  here  made 
an  enormous  step  in  advance.  Like  man v authors,  however,  he  rode 
40 


618  THE    PUERPERAL    STATE. 

his  hobby  a  little  too  hard,  and  he  erred  in  denying  the  occurrence 
of  cellulitis  in  many  cases  in  which  it  undoubtedly  exists. 

Etioloyy. — The  great  influence  of  child-birth  in  producing  these 
diseases  has  long  been  fully  recognized.  Courty  estimates  that  about 
two-thirds  of  all  the  cases  met  with  occur  in  connection  with  de- 
livery or  abortion,  and  Duncan  found  that  out  of  40  carefully  observed 
cases,  25  were  associated  with  the  puerperal  state. 

The  Inflammation  is  Secondary  and  never  Idiopathic. — It  is  pretty 
generally  admitted  by  most  modern  writers  that  both  varieties  of  the 
disease  are  produced  by  the  extension  of  inflammation  from  either 
the  uterus,  the  Fallopian  tubes,  or  the  ovaries.  This  point  has  been 
especially  insisted  on  by  Duncan,  who  maintains  that  the  disease  is 
never  idiopathic,  and  is  "  invariably  secondary  either  to  mechanical 
injury,  or  to  the  extension  of  inflammation  of  some  of  the  pelvic  vis- 
cera, or  to  the  irritation  of  the  noxious  discharges  through  or  from 
the  tubes  or  ovaries." 

Often  intimately  connected  with  Septicsemia. — Their  intimate  con- 
nection with  puerperal  septicaemia  is  also  a  prominent  fact  in  the 
natural  history  of  the  diseases.  Barker  mentions  a  curious  observa- 
tion illustrative  of  this,  that  when  puerperal  fever  is  endemic  in  the 
Bellevue  Hospital  in  New  York,  cases  of  pelvic  peritonitis  and  cel- 
lulitis are  also  invariably  met  with.  Olshausen  has  also  remarked 
that  in  the  Lying-in  Hospital  at  Halle,  during  the  autumn  vacation, 
when  the  patients  are  not  attended  by  practitioners,  and  when,  there- 
fore, the  chance  of  septic  infection  being  conveyed  to  them  is  less, 
these  inflammations  are  almost  always  aTosent.  As  inflammation  of 
the  lining  membrane  of  the  uterus,  of  the  vaginal  mucous  membrane, 
and  of  the  pelvic  connective  tissue,  are  of  very  constant  occurrence 
as  local  phenomena  of  septic  absorption,  the  connection  between  the 
two  classes  of  eases  is  readily  susceptible  of  explanation.  Schroeder, 
indeed,  goes  further,  and  includes  his  description  of  these  dis- 
eases under  the  head  of  puerperal  fever.  They  do  not,  however, 
necessarily  depend  upon  it ;  for,  although  it  must  be  admitted  that 
cases  of  this  kind  form  a  large  proportion  of  those  met  writh,  others 
unquestionably  occur  which  cannot  be  traced  to  such  sources,  but  are 
the  direct  result  of  causes  altogether  unconnected  with  the  inflam- 
mation attending  on  septic  absorption,  such  as  undue  exertion  shortly 
after  delivery,  or  premature"  coition.  Mechanical  causes  may  be- 
yond doubt  excite  the  disease  in  a  woman  predisposed  by  the  puer- 
peral process,  but  they  cannot  fairly  be  included  under  the  head  of 
puerperal  fever. 

Seat  of  the  Inflammation  in  Pelvic  Cellulitis. — Abundance  of  areolar 
tissue  exists  in  connection  with  the  pelvic  viscera,  which  may  be  the 
seat  of  cellulitis.  It  forms  a  loose  padding  between  the  organs  con- 
tained in  the  pelvis  proper,  surrounds  the  vagina,  the  rectum,  and 
the  bladder,  and  is  found  in  considerable  quantity  between  the  folds 
of  the  broad  ligaments.  From  these  parts  it  extends  upwards  to  the 
iliac  fossae,  and  the  inner  surface  of  the  abdominal  parietes.  In  any 
of  these  positions  it  may  be  the  seat  of  the  kind  of  inflammation  we 
are  discussing.  The  essential  character  of  the  inflammation  is  similar 


PELVIC    CELLULTTIS    AND    PELVIC    PERITONITIS.  619 

to  that  which  accompanies  arcolar  inflammation  in  other  parts  of  the 
body.  There  is  first  an  acute  inflammatory  oedema,  followed  by  the 
infiltration  of  the  areolro  of  the  connective  tissue  with  exudation, 
and  the  consequent  formation  of  appreciable  swellings.  These  may 
form  in  any  part  of  the  pelvis.  Thus  we  may  meet  with  them,  and 
this  is  a  very  common  situation,  between  the  folds  of  the  broad 
ligaments,  forming  distinct  hard  tumors,  connected  with  the  uterus, 
and  extending  to  the  pelvic  walls,  their  rounded  outlines  being  readily 
made  out  by  bi-rnanual  examination.  If  the  cellulitis  be  limited  in 
extent,  such  a  swelling  may  exist  on  one  side  of  the  uterus  only, 
forming  a  rounded  mass  of  varying  size,  and  apparently  attached  to 
it.  At  other  times  the  exudation  is  more  extensive,  and  may  com- 
pletely or  partially  surround  the  uterus,  extending  to  the  cellular 
tissue  between  the  vagina  and  rectum,  or  between  the  uterus  and 
the  bladder.  In  such  cases  the  uterus  is  imbedded  and  firmly  fixed 
in  dense,  hard  exudation.  At  other  times,  the  inflammation  chiefly 
affects  the  cellular  tissue  covering  the  muscles  lining  the  iliac  fossae. 
There  it  forms  a  mass,  easily  made  out  by  palpation,  but  on  vaginal 
examination  little  or  no  trace  of  the  exudation  can  be  felt,  or  only  a 
sense  of  thickness  at  the  roof  of  the  vagina  on  the  same  side  as  the 
swelling. 

Seat  of  the  Inflammation  in  Pelvic  Peritonitis. — In  pelvic  peritonitis 
the  inflammation  is  limited  to  that  portion  of  the  peritoneum  which 
invests  the  pelvic  viscera.  Its  extent  necessarily  varies  with  the 
intensity  and  duration  of  the  attach.  In  some  cases  there  may  be 
little  more  than  irritation,  while  more  often  it  runs  on  to  exudation 
of  plastic  material.  The  result  is  generally  complete  fixation  of  the 
uterus,  and  hardening  and  swelling  in  the  roof  of  the  vagina;  and 
the  lymph  poured  out  may  mat  together  the  surrounding  viscera,  so 
as  to  form  swellings,  difficult,  in  some  cases,  to  differentiate  from 
those  resulting  from  cellulitis.  On  post-mortem  examination  the 
pelvic  viscera  are  found  extensively  adherent,  and  the  agglutination 
may  involve  the  coils  of  the  intestine  in  the  vicinity,  so  as  sometimes 
to  form  tumors  of  considerable  size. 

Relative  Frequency  of  the  Two  Forms  of  Disease. — The  relative  fre- 
quency of  these  two  forms  of  inflammation. as  puerperal  affections  is 
not  easy  to  ascertain.  In  the  non-puerperal  state  the  peritonitic 
variety  is  much  the  more  common,  but  in  the  puerperal  state  they 
very  generally  complicate  each  other,  and  it  is  rare  for  cellulitis  to 
exist  to  any  great  extent  without  more  or  less  peritonitis. 

Symptomatology. — The  earliest  symptom  is  pain  in  the  lower  part 
of  the  abdomen,  which  is  generally  preceded  by  rigor  or  chilliness. 
The  amount  of  pain  varies  much.  Sometimes  it  is  comparatively 
slight,  and  it  is  by  no  means  rare  to  meet  with  patients,  who  are  the 
subjects  of  very  considerable  exudations,  who  suffer  little  more  than 
a  certain  sense  of  weight  and  discomfort  at  the  lower  part  of  the 
abdomen.  On  the  other  hand  the  suffering  may  be  excessive,  and  is 
characterized  by  paroxysmal  exacerbations,  the  patient  being  com- 
paratively free  from  pain  for  several  successive  hours,  and  then 
having  attacks  of  the  most  acute  agony.  Schroeder  says  that  pain 


620  THE    PUERPERAL    STATE. 

is  always  a  symptom  of  peritonitis,  and  that  it  does  not  exist  in 
uncomplicated  cellulitls.  The  swellings  of  cellulitis  are  certainly 
sometimes  remarkably  free  from  tenderness,  and  I  have  often  seen 
masses  of  exudation  in  the  iliac  fossae,  which  could  bear  even  rough 
handling.  On  the  other  hand,  although  this  is  certainly  more  often 
met  with  in  non-puerperal  cases,  the  tenderness  over  the  abdomen  is 
sometimes  excessive,  the  patient  shrinking  from  the  slightest  touch. 
The  pulse  is  raised,  generally  from  100  to  120,  and  the  thermometer 
shows  the  presence  of  pyrexia.  During  the  entire  course  of  the 
disease  both  these  symptoms  continue.  The  temperature  is  often 
very  high,  but  more  frequently  it  varies  from  100°  to  104°,  and  it 
generally  shows  more  or  less  marked  remissions.  In  some  cases  the 
temperature  is  said  not  to  be  elevated  at  all,  or  even  to  be  sub-nor- 
mal, but  this  is  certainly  quite  exceptional.  Other  signs  of  local 
and  general  irritation  often  exist.  Among  them,  and  most  distinctly 
in  cases  of  peritonitis,  are  nausea  and  vomiting,  and  an  anxious 
pinched  expression  of  the  countenance,  while  the  local  mischief  often 
causes  distressing  dysuria  and  tenesmus.  The  latter  is  especially 
apt  to  occur  when  there  is  exudation  between  the  rectum  and  vagina, 
which  presses  on  the  bowel.  The  passage  of  feces,  unless  in  a  very- 
liquid  form,  may  then  cause  intolerable  suffering. 

Such  symptoms  may  show  themselves  within  a  few  days  after 
delivery,  and  then  they  can  harely  fail  to  attract  attention.  On  the 
other  hand,  they  may  not  commence  for  some  weeks  after  labor,  and 
then  they  are  often  insidious  in  their  onset,  and  apt  to  be  overlooked. 
It  is  far  from  rare  to  meet  with  cases  six  weeks  or  more  after  con- 
finement, in  which  the  patient  complains  of  little  beyond  a  feeling 
of  malaise  and  discomfort,  and  in  which,  on  investigation,  a  conside- 
rable amount  of  exudation  is  detected,  which  had  previously  entirely 
escaped  observation. 

Results  of  Physical  Examination. — On  introducing  the  finger  into 
the  vagina  it  will  be  found  to  be  hot  and  swollen,  in  some  cases  dis- 
tinctly cedematous,  and  on  reaching  the  vaginal  cul-de-sac  the  exist- 
ence of  exudation  may  generally  be  made  out.  The  amount  of  this 
varies  much.  Sometimes,  especially  in  the  early  stage  of  the  disease, 
there  is  little  more  than  a  diffuse  sense  of  thickness  and  induration 
at  either  side  of,  or  behind,  the  uterus.  More  generally  careful 
bi-manual  examination  enables  us  to  detect  a  distinct  hardening  and 
swelling,  possibly  a  tumor  of  considerable  size,  which  may  appa- 
rently be  attached  to  the  sides  of  the  uterus,  and  rise  above  the 
pelvic  brim,  or  may  extend  quite  to  the  pelvic  walls.  The  examina- 
tion should  be  very  carefully  and  systematically  conducted  with 
both  hands,  so  as  to  explore  the  whole  contour  of  the  uterus  before, 
behind,  and  on  either  side,  as  well  as  the  iliac  fossae ;  otherwise  a 
considerable  exudation  might  readily  escape  detection.  "When  the 
exudation  is  at  all  great,  more  or  less  fixity  of  the  uterus  is  sure  to 
exist,  and  is  a  very  characteristic  symptom.  The  womb,  instead  of 
being  freely  movable  by  the  examining  finger,  is  firmly  fixed  by  the 
surrounding  exudation,  and  in  severe  forms  of  the  disease  is  quite 
encased  in  it.  More  or  less  displacement  of  the  organ  is  also  of 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  621 

common  occurrence.  If  the  swelling  be  limited  to  one  side  of  the 
pelvis  or  to  Douglas's  space,  the  uterus  is  displaced  in  the  opposite 
direction,  so  that  it  is  no  longer  in  its  usual  central  position. 

The  T'wo  Forms  of  Disease  cannot  always  be  Distinguished. — The 
differential  diagnosis  of  pelvic  cellulitis  and  pelvic  peritonitis  cannot 
always  be  made,  and,  indeed,  in  many  cases  it  is  impossible,  since 
both  varieties  of  disease  coexist.  The  elements  of  differentiation 
generally  insisted  on  are,  the  greater  general  disturbance,  nausea, 
etc.,  in  pelvic  peritonitis,  with  an  earlier  commencement  of  the  symp- 
toms after  labor.  The  swellings  of  pelvic  peritonitis  are  also  more 
tender,  with  less  clearly-defined  outline  than  those  of  cellulitis. 
When  the  cellulitis  involves  the  iliac  fossa  the  diagnosis  is,  of  course, 
easy,  and  then  a  continuous  retraction  of  the  thigh  on  the  affected 
side  (an  involuntary  position  assumed  with  the  view  of  keeping  the 
muscles  lining  the  iliac  fossa  at  rest),  is  often  observed.  When  the 
inflammation  is  chiefly  limited  to  the  cavity  of  the  pelvis,  the  dis- 
tinction between  the  two  classes  of  cases  cannot  be  made  with  any 
degree  of  certainty. 

Terminations. — Both  forms  of  disease  may  end  either  in  resolution 
or  in  suppuration.  In  the  former  case,  after  the  acute  symptoms 
have  existed  for  a  variable  time,  it  may  be  for  a  fewvdays  only,  it 
may  be  for  many  weeks,  their  severity  abates,  the  swellings  become 
less  tender  and  commence  to  contract,  become  harder  and  are  gradu- 
ally absorbed ;  until,  at  last,  the  fixity  of  the  uterus  disappears,  and 
it  again  resumes  its  central  position  in  the  pelvic  caVity.  This  pro- 
cess is  often  very  gradual.  If  is  by  no  means  rare  to  find  a  patient, 
even  some  months  after  the  attack,  when  all  acute  symptoms  have 
long  disappeared,  who  is  even  able  to  move  about  without  incon- 
venience, in  whom  the  uterus  is  still  immovably  fixed  in  a  mass  of 
deposit,  or  is,  at  least,  adherent  in  some  part  of  its  contour.  More 
or  less  permanent  adhesions  are  of  common  occurrence,  and  give 
rise  to  symptoms  of  considerable  obscurity,  which  are  often  not 
traced  to  their  proper  source. 

Symptoms  of  Suppuration. — When  the  inflammation  is  about  to 
terminate  in  suppuration,  the  pyrexial  symptoms  continue,  and 
eventually  well-marked  hectic  is  developed,  the  temperature  gene- 
rally showing  a  distinct  exacerbation  at  night.  At  the  same  time 
rigors,  loss  of  appetite,  a  peculiar  yellowish  discoloration  of  the  face, 
and  other  signs  of  suppuration,  show  themselves.  The  relative  fre- 
quency of  this  termination  is  variously  estimated  by  authors.  Duncan 
quotes  Simpson  as  calculating  it  as  occurring  in  half  the  cases  of 
pelvic  cellulitis,  but  states  his  own  belief  that  it  is  much  more  frequent. 
West  observed  it  in  23  out  of  43  cases  following  delivery  or  abor- 
tion, and  McClintock  in  37  out  of  70.  Schroeder  says  that  he  has 
only  once  seen  suppuration  in  92  cases  of 'distinctly  demonstrable 
exudation,  a  result  which  is  certainly  totally  opposed  to  common 
experience.  Barker  also  states  that  in  his  experience  suppuration 
in  either  pelvic  peritonitis  or.  cellulitis  "is  very  rare,  except  when 
they  are  associated  with  pyaemia  or  puerperal  fever."  It  is  certain 
that  suppuration  is  more  likely  to  occur  in  pelvic  cellulitis  than  in 


622  THE    PUERPERAL    STATE. 

pelvic  peritonitis,  but  it  unquestionably  occurs,  in  this  country  at 
least,  much  more  frequently  than  the  statements  of  either  of  these 
authors  would  lead  us  to  suppose. 

Channels  through  which  Pi(s  may  Escape. — The  pus  may  find  an 
exit  through  various  channels.  In  pelvic  cellulitis,  more  especially 
when  the  areolar  tissue  of  the  iliac  fossa  is  implicated,  the  most 
common  site  of  exit  is  through  the  abdominal  wall.  It  may,  how- 
ever, open  at  other  positions,  and  the  pus  may  find  its  way  through 
the  cellular  tissue  and  point  at  the  side  of  the  anus,  or  in  the  vagina, 
or  it  may  take  even  a  more  tortuous  course  and  reach  the  inner  sur- 
face of  the  thigh.  Pelvic  abscesses  not  uncommonly  open  into  the 
rectum  or  bladder,  causing  very  considerable  distress  from  tenesmus 
or  dysuria.  According  to  Hervieux,  it  is  chiefly  the  peritoneal 
varieties  which  open  in  this  way.  Not  unfrequently  more  than  one 
opening  is  formed;  and  when  the  pus  has  burrowed  for  any  dis- 
tance, long  fistulous  tracts  result,  which  secrete  pus  for  a  length  of 
time,  and  are  very  slow  to  heal.  Rupture  of  an  abscess  into  the 
peritoneal  cavity,  especially  of  a  peritonitic  abscess,  is  a  possible 
(but  fortunately  a  very  rare)  termination,  and  will  generally  prove 
fatal  by  producing  general  peritonitis.  In  one  case  which  I  have 
recorded  in  the  fifteenth  volume  of  the  u  Obstetrical  Transactions," 
suppuration  was  folloAved  by  extensive  necrosis  of  the  pelvic  bones. 
Two  similar  cases  are  related  by  Trousseau  in  his  "  Clinical  Medi- 
cine," but  I  have  not  been  able  to  meet  with  any  other  examples  of 
this  rare  complication,  which  was  probably  rather  the  result  of  some 
obscure  septicaernic  condition  than  of  extension  of  the  inflammation. 

Prognosis. — The  prognosis  is  favorable  as  regards  ultimate  re- 
covery, but  there  is  greak  risk  of  a  protracted  illness  which  may 
seriously  impair  the  health  of  the  patient,  especially  if  suppuration 
result.  Hence  it  is  necessary  to  be  guarded  in  an  expression  of 
opinion  as  to  the  consequences  of  the  disease.  Secondary  mischief 
is  also  far  from  unlikely  to  follow,  from  the  physical  changes  pro- 
duced by  the  exudation,  such  as  -permanent  adhesions  or  malpositions 
of  the  uterus,  or  organic  alterations  in  the  ovaries  or  Fallopian  tubes. 

Treatment. — In  the  treatment  of  both  forms  of  disease  the  import- 
ant points  to  bear  in  mind  are  the  relief  of  pain,  and  the  necessity 
of  absolute  rest ;  and  to  these  objects  all  our  measures  must  be  sub- 
ordinate, since  it  is  quite  hopeless  to  attempt  to  cut  short  the  inflam- 
mation by  any  active  medication. 

If  the  disease  be  recognized  at  a  very  early  stage,  the  local  abstrac- 
tion of  blood,  by  the  application  of  a  few  leeches  to  the  groin  or  to  the 
hemorrhoidal  veins,  may  give  relief;  but  the  influence  of  this  remedy 
has  been  greatly  exaggerated,  and  when  the  disease  is  of  any  standing 
it  is  quite  useless.  Leeches  to  the  uterus,  often  recommended,  are,  I 
believe,  likely  to  do  more  harm  than  good  (unless  in  very  skilful 
hands),  from  the  irritation  produced  by  passing  the  speculum.  Opi- 
ates in  large  doses  may  be  said  to  be  our  sheet  anchor  in  treatment 
whenever  the  pain  is  at  all  severe,  either  by  the  mouth,  in  the  form 
of  morphia  suppositories,  or  injected  subcutaneously.  In  the  not 
uncommon  cases  in  which  pain  comes  on  severely  in  paroxysms,  the 


PELVIC    CELLULITIS    AND    PELVIC    PERITONITIS.  623 

opiates  should  be  administered  in  sufficient  quantity  to  lull  the  pain, 
and  it  is  a  good  plan  to  give  the  nurse  a  supply  of  morphia  supposi- 
tories (which  often  act  better  than  any  other  form  of  administering 
the  drug),  with  directions  to  use  them  immediately  the  pain  threatens 
to  corne  on.  When  there  is  much  pyrexia  large  doses  of  quinine 
may  be  given  with  great  advantage,  along  with  the  opiates.  The 
state  of  the  bowels  requires  careful  attention.  The  opiates  are  apt 
to  produce  constipation,  and  the  passage  of  hardened  feces  causes 
much  suffering  Hence  it  is  desirable  to  keep  the  bowels  freely 
open.  Nothing  answers  this  purpose  so  well  as  small  doses  of  castor 
oil,  such  as  half  a  teaspoonful  given  every  morning.  Warmth  and 
moisture,  constantly  applied  to  the  lower  part  of  the  abdomen,  give 
great  relief  either  in  the  form  of  large  poultices  of  linseed  meal,  or, 
if  these  prove  too  heavy,  of  spongio-piline  soaked  in  boiling  water. 
The  poultices  may  be  advantageously  sprinkled  with  laudanum  or 
belladonna  liniment.  I  say  nothing  of  the  use  of  mercurials,  iodide 
of  potassium,  and  other  so-called  absorbent  remedies,  since  I  believe 
them  to  be  quite  valueless,  and  apt  to  divert  attention  from  more 
useful  plans  of  treatment. 

Importance  of  Rest. — The  most  absolute  rest  in  the  recumbent  posi- 
tion is  essential,  and  it  should  be  persevered  in  for  some  time  after 
the  intensity  of  the  symptoms  is  lessened.  The  beneficial  effect  of 
rest  in  alleviating  pain  is  often  seen  in  neglected  cases,  the  nature  of 
which  has  been  overlooked,  instant  relief  following  the  laying  up 
of  the  patient. 

Counter -Irritation. — When  the  acute  symptoms  have  lessened,  ab- 
sorption of  the  exudation  may  be  favored,  and  considerable  relief 
obtained,  from  counter-irritation,  which  should  be  gentle  and  long- 
continued.  The  daily  use  of  tincture  of  iodine  until  the  skin  peels, 
perhaps  best  meets  this  indication ;  but  frequently  repeated  blisters 
are  often  very  serviceable.  This  I  believe  to  be  a  better  plan  than 
keeping  up  an  open  sore  with  savine  ointment,  or  similar  irritating 
applications. 

Opening  of  Pelvic  Abscesses. — When  suppuration  is  established  the 
question  of  opening  the  abscess  arises.  When  this  points  in  the 
groin,  and  the  matter  is  superficial,  a  free  incision  may  be  made,  and 
here,  as  in  mammary  abscess,  the  antiseptic  treatment  is  likely  to 
prove  very  serviceable.  The  abscess  should,  however,  not  be  opened 
too  soon,  and  it  is  better  to  wait  until  the  pus  is  near  the  surface. 
The  importance  of  not  being  in  too  great  a  hurry  to  open  pelvic 
abscesses  has  been  insisted  on  by  West,  Duncan,  and  other  writers, 
and  I  have  no  doubt  the  rule  is  a  good  one.  It  is  more  especially 
applicable  when  the  abscess  is  pointing  in  the  vagina  or  rectum, 
where  exploratory  incisions  are  apt  to  be  dangerous,  and  when  the 
presence  of  pus  should  be  positively  ascertained  before  operating. 
We  have  in  the  aspirator  a  most  useful  instrument  in  the  treatment 
of  such  cases,  which  enables  us  to  remove  the  greater  part  of  the  pus 
without  any  risk,  and  the  use.of  which  is  not  attended  with  danger, 
even  if  employed  prematurely.  If  it  do  not  sufficiently  evacuate  the 
abscess,  a  free  opening  can  afterwards  be  safely  made  with  the  bis- 


624  THE    PUERPERAL    STATE. 

toury.    The  surgical  treatment  of  pelvic  abscess  is,  however,  too  wide 
a  subject  to  admit  of  being  satisfactorily  treated  here. 

Diet  and  Regimen. — The  diet  should  be  abundant,  but  simple  and 
nutritious.  In  the  early  stages  of  the  disease,  milk,  beef-tea,  eggs, 
and  the  like,  will  be  sufficient.  After  suppuration  a  large  quantity 
of  animal  food  is  required,  and  a  sufficient  amount  of  stimulants. 
The  drain  on  the  system  is  then  often  very  great,  and  the  amount  of 
nourishment  patients  will  require  and  assimilate,  when  a  copious 
purulent  discharge  is  going  on,  is  often  quite  remarkable.  A  general 
tonic  plan  of  medication  will  also  be  required,  and  such  drugs  as 
iron,  quinine,  and  cod-liver  oil,  will  prove  useful. 


[APPENDIX. 


THE  INTRA- VENOUS  INJECTION  OF  FRESH  MILK,  AS  AN  IMPROVED 
SUBSTITUTE  FOR  THE  TRANSFUSION  OF  BLOOD. 

THE  introduction  of  freshly  drawn,  blood- warm  milk,  of  the  cow 
and  goat,  into  the  veins  of  an  exhausted  patient,  whether  the  condi- 
tion is  the  result  of  hemorrhage  or  disease,  is  not  altogether  new  as 
a  means  of  physical  restoration,  but  has  been  recently  revived  with 
improvements,  both  as  to  method  and  application,  by  several  Ame- 
rican physicians,  most  prominent  among  whom  is  Dr.  T.  Gaillard 
Thomas,  of  New  York. 

The  credit  of  the  initiative  revival  is  due  to  Dr.  Edward  M. 
Hodder,  of  Toronto,  Canada,  who  made  use  of  it  in  the  collapse  of 
Asiatic  cholera,  with  the  saving  of  two  patients,  in  the  epidemic  of 
1850,  when  warm  water,  artificial  serum,  etc.,  were  being  injected 
experimentally  but  ineffectually  into  the  bloodvessels  of  patients. 
Dr.  Joseph  W.  Howe,  of  New  York,  instituted  a  series  of  experi- 
ments upon  dogs ;  but,  using  milk  brought  from  the  country,  all  of 
his  animals  promptly  died.  Dr.  Depuy  repeated  the  same,  with 
immediately  drawn  milk,  and  found  the  fluid  perfectly  harmless  in 
this  form.  Dr.  Howe  injected,  also,  f^vj  of  goat's  milk  into  the 
cephalic  vein  of  a  patient  affected  with  phthisis,  with  success,  so  far 
as  the  immediate  effect  was  concerned. 

Dr.  Thomas  presented  an  account  of  his  cases  in  a  paper  read 
before  the  New  York  Academy  of  Medicine  last  spring,  an  abridg- 
ment of  which  appeared  in  the  Medical  Record  of  April  27th,  1878. 
His  first  trial  was  made  in  October,  1875,  in  a  case  of  uterine  hemor- 
rhage following  ovariotomy,  with  f ^viiiss  of  warm  and  freshly  drawn 
cow's  milk,  the  medium  of  introduction  being  a  glass  funnel,  India- 
rubber  tube,  and  nozzle.  A  rigor  resulted,  followed  by  a  rise  of 
temperature  to  104°,  but  these  symptoms  soon  disappeared.  The 
patient  made  a  good  recovery,  being  down  stairs  on  the  twenty-first 
day. 

In  a  second  ovarian  case,  Dr.  Thomas  injected  on  five  occasions, 
from  f  §vj  up  to  f  Jxv,  in  a  period  of  ten  days ;  and  although  the 
patient  died  of  intestinal  gangrene,  the  impression  was  that  the  milk 
had  prolonged  her  life  about  six  days. 

As  far  as  we  have  ascertained,  there  have  been  fifteen  patients 
under  treatment  by  this  method,  viz.,  Dr.  Hodder,  three  cases ;  Dr. 


626  APPENDIX. 

Howe,  two  ;  Dr.  Thomas,  seven  ;  and  Dr.  Charles  T.  Hunter,  of  Phila- 
delphia, three. 

Dr.  Hunter  greatly  prefers  this  method  to  that  of  the  transfusion 
of  blood,  over  which  it  has  many  advantages,  both  in  introduction 
and  result.  He  has  the  milk  drawn  into  a  double  vessel,  with  warm 
water  in  the  interspace,  and  regulates  the  temperature  to  about  99° 
Fahr.  The  fluid  is  strained  through  fine  wire  gauze,  to  exclude  any 
foreign  matters  that  might  be  injurious.  Attached  to  the  funnel  and 
tube,  Dr.  Hunter  has  a  perforating  canula,  with  a  small  stopcock  to 
shut  off'  the  flow  of  milk.  After  the  vein  is  fully  exposed,  the  milk 
is  run  through  the  tube,  the  cock  closed,  which  keeps  the  canula  full 
by  capillary  attraction,  and  the  vessel  perforated  by  the  cutter  on  the 
end  of  the  canula ;  the  cock  is  then  opened,  funnel  elevated,  and 
milk  carried  in  by  its  own  weight.  He  has  used  cows'  milk  in  two 
cases,  and  goats'  milk  in  the  third  and  last.  He  objects  to  the  use  of 
the  syringe  as  much  more  troublesome  and  less  safe  than  the  simple 
fountain  apparatus  described. 

The  milk  used  should  not  only  be  just  drawn,  but  perfectly  free 
from  any  acidity,  as  shown  by  test-paper.  In  hot  weather,  the  passage 
of  milk  through  the  air  from  the  udder  to  the  vessel  will  develop  a 
slight  formation  of  lactic  acid,  which  should  be  neutralized  by  the 
addition  of  bicarbonate  of  soda.  Dr.  A.  Jacobi,  in  the  discussion  of 
Dr.  Thomas's  paper,  stated  that  the  milk  of  some  cows  was  acid  while 
still  in  the  udder.  The  cow,  or  goat,  should  be  fed  upon  grass  or 
fine  hay,  and  be  milked  as  near  to  the  patient  as  possible,  into  the 
double  vessel  already  described,  or,  what  will  answer,  a  clean  farina- 
boiler  or  glue-pot,  both  of  which  are  double-cased.  In  the  country 
this  can  be  readily  managed  so  far  as  the  cow  is  concerned,  as  she 
can  be  driven  to  the  door  to  be  milked ;  but  in  cities  there  is  much 
more  difficulty,  where  this  animal  is  rarely  kept,  and  we  are  obliged 
to  use  the  goat  as  a  substitute,  feeding  her  in  the  yard  or  cellar  for 
the  time  wanted.  No  doubt  the  milk  of  the  ass  or  mare,  when  at 
hand,  would  answer  equally  well.  Both  Dr.  Thomas  and  Dr.  Hunter 
believe  that  a  measure  of  f ^viij  is  sufficient  for  ordinary  use,  although 
the  former  has  used  as  high  as  fifteen,  and  the  latter  ten.  We  be- 
lieve that  the  size  of  the  patient  should  make  a  difference  in  the 
number  of  ounces  to  be  employed,  just  as  it  does  in  the  volume  of 
blood  naturally  in  the  body,  the  range  in  the  extremes  being  con- 
siderable. As  chyle  varies  in  color  and  analysis  according  to  the 
food  consumed,  being  most  nearly  allied  to  milk  when  the  animal 
has  been  fed  with  it,  there  must  be  in  the  blood  a  capability  of  con- 
version, of  a  variable  character,  which  enables  it  to  alter,  not  only 
the  extremes  of  the  chylous  fluid,  but  milk  also,  with  its  butter  and 
casein,  which  are  not  found  in  chyle.  Pure  milk  has  been  satisfac- 
torily proved  to  be  innocent  in  the  blood  when  properly  collected 
and  introduced ;  and  not  only  this,  but  also  a  valuable  means  of 
saving  life  in  cases  of  extreme  prostration.  How  it  acts,  we  do  not 
understand ;  or  why  it  will  answer  as  well  as,  or  better  than,  blood ; 
we  are  satisfied  that  it  does,  and  are  prepared  to  recommend  it  to 
our  readers. 


APPENDIX.  (j'll 

We  have  a  patient,  almost  in  articulo-niortis,  pale,  prostrate,  per- 
haps emaciated  and  an?emic,  lying  in  a  semi-comatose  sleep,  into 
whose  veins  we  inject  a  half  pint  of  pure,  warm,  new  milk.  She 
has  a  chill,  then  a  considerable  rise  of  temperature,  and  finally  opens 
her  eyes  and  appears  for  the  time  as  one  almost  awakened  from  the 
sleep  of  death.  If  the  condition  of  the  patient  is  not  necessarily  fatal, 
bv  reason  of  its  destructive  progress,  we  may  bridge  over  the  period 
of  danger  until  convalescence  is  established,  and  thus  save  the  case. 
Milk  has  done  this  when  food  and  stimulants  appeared  to  be  unavail- 
able ;  and  we  have  faith  to  believe,  that  it  has  a  future  of  much  use- 
fulness in  a  great  variety  of  cases.  To  make  known  its  value,  is  to 
largely  increase  its  sphere  of  usefulness  in  general  practice. — Eu.] 


INDEX. 


ABDOMEN,  adipose  enlargement  of,  148 
enlargement   of,   as   a  sign  of  preg- 
nancy, 139 

state  of,  after  delivery,  526 
Abdominal  pregnancy.    (See  Extra-uterine 

pregnancy.) 
Abortion,  229 

causes  of,  231 

difficulty  in  procuring  artificial,  230 

liability  to  recurrence  of,  230 

retention  of  secundines  in,  235,  240 

symptoms  of,  235 

treatment  of,  235 

production   of,   in   vomiting  of  preg- 
nancy, 187 

[value  of  opium  in  prevention  of,  236] 
Abscess  of  mammse.     (See  Mammary  ab- 
scess.) 

Abscess,  pelvic.     (See  Pelvic  cellulitus.) 
After-pains,  529 

treatment  of.  531 
Age,  influence  of,  in  labor,  328 
Albuminuria  in  pregnancy,  192 

relation  of,  to  eclampsia,  550 

relation  of,  to  puerperal  insanity,  563 
Allantois,  96 
Anmion,  formation  of,  95 

pathology  of,  223 

structure  of,  98 

Amputations  (intra-uterine),  226 
Anjemia  in  pregnancy,  191 
Anaesthesia  in  labor,  282 

in  forceps  operations,  465 

value  of,  in  difficult  cases  of  turning, 

457 

Anasarca  in  pregnancy,  194 
Ante-version  of  the  gravid  uterus,  202 
Apoplexy  during  or  after  labor,  550,  606 
Arbor  vitse,  51 
Area  germinativa,  94 
Area  pellucida,  95 
Areola,  70 

changes  of,  during  pregnancy,  136 
Arm,  presentation  of.     (See  Shoulder  pre- 
sentation.) 

dorsal  displacement  of,  318 
Artificial  human  milk,  547 
Artificial  respiration  in  cases  of  apparent 

still-birth,  534 

Ascites  as  a  cause  of  dystocia,  364 
Asphyxia  (idiopathic),  607 


[Atmosphere,  advantages  of  a  pure,    in 

preventing  abortion,  237] 
Auscultatory  signs  of  pregnancy,  142 


BAGS  (Barnes's).     (See  Dilators.) 
Ballottement,  141 
Bi-lobed  uterus,  gestation  in,  180 
Binder,  uses  of,  281 

Bladder,  distension  of,  as  a  cause  of  pro- 
tracted labor,  328 
state  of,  after  delivery,  530 
Blastodermic  membrane,  88 

division  and  layers  of,  94 
Blood,  alteration  in,  after  delivery,  524 
Blood-diseases  transmitted  to  foetus,  223 
Blunt-hook  in  breech  presentation,  297 
Bowels,  action  of,  after  delivery,  532 
Breech   presentations.     (See   Pelvic  pre- 
sentations.) 

Broad  ligaments  of  uterus,  59 
[Bromide  of  sodium  preferred  to  bromide 

of  potassium,  196] 
Bronchitis  as  a  cause  of  protracted  labor, 

328 
Brow  presentations,  306 


fl^ESAREAN  section,  203,  317,  345,  375, 
\J  499 

causes  of  mortality  after,  504 
causes   requiring   the  operation, 

501 

description  of,  508 
history  of,  499 
post-mortem  operation,  503 
results  to  child  in,  501 
statistics  of,  501 
substitutes  for,  510 
[Csesarean  operation  in  the  United  States, 

512.] 
[carbolized    catgut    sutures    in, 

509] 
[transverse    position    of    fetus, 

499] 

Calculus  of  bladder  obstructing  labor,  347 
Caput  succedaneum,  266 
Carcinoma  in  pregnancy,  209 

obstructing  labor,  314 
Caries  of  teeth  in  pregnancy,  190 
Carunculse  myrtiformes,  44 


630 


INDEX. 


[Catheter  introduced  in  dorsal  decubitus, 

43] 

introduction  of,  43 
Caul,  251 

Cellulitis,  pelvic.     {See  Pelvic  cellulitis.; 
Cephalotribe,  487 

Cephalotripsy.     (See  Craniotomy.) 
Cervix  uteri,  51 

alterations  of,  after  childbirth,  50 
cavity  of,  50 

dilatation  of,  in  labor,  246 
impaction  of,  before  foetal  head, 

274 

incision  of,  for  rigidity,  342 
modification    of,    by   pregnancy, 

126 

mucous  membrane  of,  55 
organic  causes  of  rigidity  of,  341 
rigidity  of,    as   a   cause   of  pro- 
tracted labor,  339 
treatment  of  rigidity,  340 
villi  of,  55 

Charlotte,  Princess  of  Wales,  death  of,  336 
Child  (the  new  born).     (See  Infant.) 
Child,  risks  to,  in  forceps  operations,  472 
Childbirth,  mortality  of,  523 
Chloral  in  labor,  283 

in  rigidity  of  cervix,  340 
Chloroform  in  labor,  283 

in  difficult  cases  of  turning,  457 
in  rigidity  of  cervix,  340 
Chorea  in  pregnancy,  198 
Chorion,  99 

vesicular  degeneration  of,  215 
Circulation  of  foetus,  119 
Cleavage  of  yelk,  88 
Clitoris,  42 
Coccyx,  27 

ligaments  of,  28 
ossification  of,  28 
mobility  of,  28 
Cold  in  the  treatment  of  puerperal  hyper- 

pyrexia,  592 
Colostrum,  536 
Complex  presentations,  317 
Conception,  signs  of,  133 
Constipation  in  pregnancy,  188 
[Constriction  of  uterus,  tetanoid,  350] 
Continued  fever  in  pregnancy,  207 
Convulsions   (puerperal).     (See   Eclamp- 
sia.) 

Corps  reticule,  97 
Corpus  luteum,  74 
Cranioclast,  487 
Craniotomy,  484 

cases  requiring,  490 

comparative  merits  of,  and  cephalo- 

tripsy,  493 

description  of  cephalotripsy,  494 
extraction  of  head  by  craniotomy  for- 
ceps, 496 

method  of  perforating,  492 
perforators,  486 

perforation  of  after-coming  head,  493 
religious  objections  to,  484 


Craniotomy  forceps,  488 

Crotchets,  486 

Cystocele,  obstructing  labor,  347 


DEATH,    apparent,   of  new-born  child. 
(See  Infant.) 
Death,  sudden,  during  labor  and  the  puer 

peral  state,  607 
from  air  in  the  veins,  608 
functional  causes  of,  608 
organic  causes  of,  607 
Decapitation  of  foetus,  497 
Decidua,  89 

at   end  of  pregnancy,  and   after  de- 
livery, 93 

cavity  between  d.  vera  and  reflexa,  93 
divisions  of,  89 
fatty  degeneration  of,  as  the  cause  of 

labor,  243 

formation  of  d.  reflexa,  91 
structure  of,  90 

Delivery,  state  of  patient  after,  524 
contraction  of  uterus  after,  526 
management  of  patient  after,  530 
nervous  shock  after,  524 
prediction  of  date  of,  152 
signs  of  recent,  155 
state  of  pulse  after,  524 
weight  of  uterus  after,  526 
Diameters  of  foetal  skull,  111 

of  pelvis,  33 

Diarrhoea  in  pregnancy,  188 
[Diet,  milk,  in  nursing  mothers,  537] 

of  lying-in  women,  531 
Dilators  (caoutchouc)  in  the  induction  of 

premature  labor,  439 
in  rigidity  of  cervix,  341 
Diphtheria  in  the  puerperal  state,  571 
Diseases  of  pregnancy,  183 
albuminuria,  192 
anemia  and  chlorosis,  191 
carcinoma,  209 
cardiac  diseases,  208 
chorea,  198 
constipation,  188 
diarrhoea,  188 
disorders  of  the  nervous  system, 

196 

respiratory  organs,  190 
teeth,  190 

urinary  system,  198 
displacements  of  the  gravid  ute- 
rus, 201 
epilepsy,  209 
eruptive  fevers,  206 
fibroid  tumors,  211 
haemorrhoids,  189 
icterus,  209 
leucorrhoca,  200 
ovarian  tumor,  210 
palpitation,  191 
paralysis,  197 
pneumonia,  207 
pruritus,  200 


INDEX. 


Diseases  of  pregnancy — 
ptyalism,  189 
syncope,  191 
syphilis,  208 
varicose  veins,  201 
vomiting  (excessive),  184 

Dropsies  affecting  the  foetus,  225 

Ductus  arteriosus,  119 
venosus,  119 

Dystocia  from  fetus,  353 


T7CLAMPSIA,  550 

Ju     cause  of  death  in,  553 

condition  of  patient  between  the  at- 
tacks, 552 

confusion    from   defective    nomencla- 
ture, 550 

exciting  causes  of,  555 
[intermittent,  559] 
obstetric  management  in,  558 
pathology  of,  553 
premonitory  symptoms  of,  550 
relation  of,  to  labor,  552 
results  to  mother  and  child  in,  552 
symptoms  of,  551 
transfusion  in,  515 
Traube   and   Rosenstein's  theory  of, 

554 

treatment  of,  555 
urzemic  theory  of,  550 
Ecraseur,  use  of,  as  a  substitute  for  crani- 

otomy,  489 

Embolism.     (See  Thrombosis.) 
Embryotomy,  497 
Emotion,  mental,  as  a  cause  of  protracted 

labor,  328 
Epiblast,  94 

Epilepsy,  in  pregnancy,  209 
Epileptic  convulsions,  550 
Ergot  of  rye,  331 

as  a  means  of  inducing  labor,  438 
objections  to  use  of,  331  t 

mode  of  administration,  331 
value  of,  after  delivery,  281 
Eruptive  fevers  in  pregnancy,  206 
Erysipelas,  as  a  cause  of  puerperal  septi- 
caemia, 577 
Ether  in  labor,  285 

[in  the  United  States,  285] 
Exhaustion,  importance  of  distinguishing 
between  temporary  and  permanent  in 
labor,  331 
Expression,  uterine.     (See  Pressure.) 

of  the  placenta,  280 
Extra-uterine  pregnancy,  163 

abdominal  variety  of,  173 

causes  of,  165 

changes  of  the  foetus  in,  175 

classification  of,  164 

diagnosis  of  abdominal  variety, 

176 

diagnosis  of  tubal  variety,  169 
gastrotomy  in,  172,  177 
pseudo-labor  in,  175 


Extra-uterine  pregnancy — 

symptoms  of  rupture  in,  168 
treatment  after  rupture,  172 
treatment  of  abdominal  variety, 

ITS 

tubal  variety,  166 
treatment  of  tubal  variety,  170 

Evisceration,  498 


FACE  presentation,  297 
causes  of,  298 
diagnosis  of,  299 
difficulties  connected  with,  305 
erroneous  views   formerly  enter- 
tained of,  297 

mechanism  of  delivery  in,  299 
mento-posterior  positions  in,  304 
prognosis  in,  304 
treatment  of,  304 
Fallopian  tubes,  61 
False  pains,  character  and  treatment  of. 

270 

Faradization,  in  apparent  still  birth,  535 
Fibroid  tumor  in  pregnancy,  211 

obstructing  labor,  344 
Fillet,  482 

in  breech  presentations,  296 
[Japanese,  484] 
nature  of  the  instrument,  482 
objections  to  its  use,  483 
Foetal  head,  anatomy  of,  110 

induction  of  premature  labor,  for 

large  size  of,  435 
Foetal   heart,   sounds   of,    in    pregnancy, 

142 

Foetus,  anatomy  and  physiology  of,  107 
[anencephalous,    causing    eneuresis, 

199] 

appearance  of  a  putrid,  228 
appearance  of,  at  various  stages  of  de- 
velopment, 108 
at  term,  109 
circulation  of,  119 
changes  in  circulation  of,  as  cause  of 

labor,  242 

changes  in.  position  of,  during  preg- 
nancy, 113 
death  of,  228 

detection  of  position  in  utero  by  pal- 
pation, 113 
early  viability  of,  229 
excessive  development  of,  as  a  cause 

of  difficult  labor,  364 
explanation  of  its  position  in  utero, 

114 

functions'of,  116 
nutrition  of,  116 
pathology  of,  222 
position  of,  in  utero,  112 
respiration  of,  118 
signs  and  diagnosis  of  death  of,  228, 

493 

Fontanelles,  110 
Foot,  diagnosis  of,  289 


632 


INDEX. 


Foot  presentations.     (See  Pelvic  presenta- 
tions.) 

Foramen  ovale,  119 
Forceps,  458 

action  of,  462 

advantages  of  pelvic  curve  in,  459 

[application  at  inferior  strait,  478] 

[at  superior  strait,  480] 
application  of,  to  after-coming  head  in 

breech  presentations,  295 
application  of,  within  the  cervix,  343 
[carried  over  abdomen,  to  complete 

delivery  of  head,  481] 
cases  in  which  a  straight  instrument 

should  be  used,  459 
dangers  of,  335,  471 
dangers  of,  to  child,  472 
description  of,  458 
description  of  the  operation,  465 
difference  between  high  and  low  ope- 
rations, 464 
disadvantages  of  a  weak  instrument, 

461 
frequent  use  of,  in  modern  practice, 

333,  458 

high  operations,  470 
long,  460 
preliminary     considerations      before 

using,  464 
short,  458 
use  of  anaesthetics  in  forceps  delivery, 

465 

use  of  in  deformed  pelvis,  382 
use   of  in  difficult  occipito-posterior 

positions,  308 

use  of  in  protracted  labor,  333 
[Forceps,  Bedford's,  476] 
[Clemann's,  462] 
[Davis's,  475] 
[Elliot's,  476] 
[Hodge's,  474] 
[Meigs's  Craniotomy,  496] 
[Sawyer's,  477] 
[Wallace's,  475] 
[White's,  476] 
Forceps-saw,  489 

[Forcipe  compressore,  Assalini's,  487] 
Fossa  navicularis,  44 
Funis.     (See  Umbilical  cord.) 


p  ALACTAGOGUES,  541 

\J     Galactorrhcea,  542 

Galvanism  as  a  means  of  inducing  labor, 
438 

Gangrene  of  limbs  from  arterial  obstruc- 
tion, 594 

Gastrotomy,  after  rupture  of  uterus,  425 
in  extra-uterine  pregnancy,  171,  179 

Gastro-elytrotomy.      (See  Laparo-elytrot- 
omy.) 

Generative  organs,  in  the  female,  41 

division  according  to  function,  41 

Germinal  vesicle,  disappearance  of,  after 
impregnation,  87 


Gestation.     (See  Pregnancy.) 
Graafian  follicle,  65 

structure  of,  67 


mEMATOCELE,  obstructing  labor,  348 
11     Haemorrhoids,  in  pregnancy,  189 
[Hand,  introduction  of,  in  occipito-poste- 
rior positions,  308] 
Hand-feeding  of  infants,  546 
ass's  milk  in,  546 
artificial  human  milk  in,  547 
causes  of  mortality  in,  546 
cow's  milk  in,  and  its  prepara- 
tion, 546 

goat's  milk  in,  546 
method  of,  548 

[Harris  on  early  puberty,  76] 
Head  presentations,  255 

description    of  cranial   positions 

in,  256 

division  of,  256 
explanation  of  frequency  of  1st 

position,  257 
frequency  of,  256 
mechanism  of  1st  position,  359 
2d  position,  264 
3d  position,  265 
4th  position,  266 
relative  frequency  of  various  po- 
sitions, 257 
Heart,  diseases  of,  in  pregnancy,  208 

hypertrophy  of,  in  pregnancy,  130 
Hemorrhage,  accidental,  399 

causes  and  pathology  of,  400 

concealed  internal,  401 

diagnosis,  prognosis,  and   treatment 

of  concealed  internal,  400 
prognosis  of,  401 
symptoms  and  diagnosis  of,  400 
treatment  of,  402 
Hemorrhage  after  delivery,  402 
causes  of,  403 
constitutional   predisposition  to, 

407 

curative  treatment  of,  409 
from  laceration  of  maternal  struc- 
tures, 415 
nature's  mode  of  preventing,  253, 

403 

preventive  treatment  of,  408 
secondary  causes  of,  405 
secondary  treatment  of,  415 
symptoms  of,  407 
transfusion  of  blood  in,  416 
Hemorrhage  after   delivery   (secondary), 

416 

distinction  between,  and  pro- 
fuse lochial  discharge,  416 
local  causes  of,  417 
treatment  of,  418 
Hemorrhage,  unavoidable.    (See  Placenta 

prsevia.) 

Hernia,  in  labor,  347 
Hour-glass  contraction  of  uterus,  405,  [406] 


INDEX. 


633 


Hydatids  of  uterus,  215 
Hydramnios,  222 

Hydrocephalus  of  fcetus,  as  a  cause  of  dif- 
ficult labor,  361 
Hydrorrhoea  gravidarum,  214 
Hymen,  43 

[an  obstacle  to  delivery,  44] 
Hypoblast,  94 
Hysteria  during  labor,  550 


INDUCTION  of    premature  labor.     (See 
Premature  labor.) 

Inertia  of  the  uterus,  frequent  child-bear- 
ing as  a  cause  of,  327 
Infant,  apparent  death  of,  533 

appearance  of,   in  cases  of  apparent 

death,  534 
clothing  of,  536 
evils  of  over-suckling,  536 
management  of,  538 
management  of,  when  food  disagrees, 

549 

treatment  of  apparent  death  of,  534 
various  kinds  of  food  of,  549 
washing  and  dressing  of,  535 
Infantile  mortality,   diminution  of,   as  a 
re&soii  for  more  frequent  use  of  forceps, 
335 
Inflammatory  diseases  affecting  the  foetus, 

225 
Insanity  (puerperal),  559 

classification  of,  559 
of  lactation,  565 
of  pregnancy,  560 
predisposing  causes  of,  560 
puerperal  (proper),  562 
causes  of,  562 
form  of,  561 
prognosis  of,  564 
post-mortem  signs  of,  565 
symptoms  of,  565 
transient  mania  during  delivery, 

561 

treatment  of,  567 
treatment  during  convalescence, 

570 
question  of  removal  to  an  asylum, 

569 

Insomnia  in  pregnancy,  196 
Intermittent    fever    affecting   the    foetus, 

224 
Intestines,    disorders   of,    as    influencing 

labor,  328 

Inversion  of  uterus.     (See  Uterus.) 
Irregular  uterine  contractions  after  labor, 

405 
as  a  cause  of  lingering  labor, 

329 

Irritable  bladder  in  pregnancy,  199 
Ischium,  planes  of  the,  38 


JAUNDICE  in  pregnancy,  209 
t) 

41 


T7IESTEIN,  132,  [133] 

J\     Knots  on  the  umbilical  cord,  221 

Knee  presentation,  288 

Kyphotio  deformity  of  pelvis,  373 


LABI  A  major  a,  41 
Labia  minora,  42 
Labor,  242 

age,  influence  of,  on,  328 

anaesthesia  in,  282 

arrest  of,  155 

causes  of,  242 

causes  of  precipitate,  338    ' 

causes  of  protracted,  326 

character  and  source  of  pain  in,  248 

character  of  false  pains,  270 

dilatation  of  cervix  in,  246 

duration  of,  254 

effect  of  uterine  contractions  in,  244 

evil  effects  of  protracted,  324 

induction  of.  (See  Premature  labor.) 

influence  of  stage  of,  in  protracted, 
325 

management  of,  in  deformed  pelvis, 
381 

management  of  natural,  268 

management  of  third  stage  of,  278 

mechanism  of,  in  head  presentation, 
256 

obstructed  by  faulty  condition  of  the 
soft  parts,  339 

period  of  day  at  which  labor   com- 
mences, 255 

phenomena  of,  242 

position  of  patient  during,  272 

preparatory  treatment,  268 

precipitate,  338 

prolonged  and  precipitate,  324 

rupture  of  membranes  in,  246 

stages  of,  249 

symptoms  of  protracted,  326 

treatment  of  protracted,  329 
Lactation,  defective  secretion  of  milk  in, 
541 

diet  of  nursing  women  during,  539 

excessive  flow  of  milk  in,  542 

importance  of  to  mother,  537 

importance  of  wet-nursing  to  child, 
537 

insanity  of,  565 

management  of,  538 

means  of  arresting  secretion  of  milk 
in,  540 

period  of  weaning  in,  540 
Laminae  dorsales,  95 
Laparo-elytrotomy,  511 
Lead-poisoning,  affecting  the  foetus,  224 

as  a  cause  of  abortion,  234 
Leucorrhoea,  in  pregnancy,  200 
Lever.     (See  Vectis.) 
[Line,  dark  abdominal,  in  negro,  138] 
Liquor  amnii,  98 

itses  of,  99 


634 


INDEX. 


Liquor  amnii — 

source  of,  99 
deficiency  of,  223 
Lochia,  528 

variation  in  amount  and  duration  of, 

529 

occasional  fetor  of,  529 
Lying-in  hospitals,  mortality  in,  571 
Lypothemia,  191 


1TALPRESENTATIONS,  peculiar  form  of 
111     bag  of  membranes  in,  288 
Mammary%bscess,  542 

antiseptic  treatment  of?  544 
signs  and  symptoms  of,  543 
treatment  of,  543 
changes  during  pregnancy,  136 
their  diagnostic  value,  138 
glands,  69 

their  sympathetic  relations  with 

the  uterus,  71 
[McKnight's  operation,  171] 
Measles,  affecting  the  fetus,  224 

in  pregnancy,  207 
Meconium,  122 
Membranes,  artificial  rupture  of,  273 

puncture  of,  as  a  means  of  inducing 

labor,  437 
Menstruation,  71 
cessation  of,  82 

during  pregnancy,  134 
changes  in  Graafian  follicle  after,  72 
[increased  by.change  of  residence  to 

a  hot  climate,  78] 
period  of,  duration,  and  recurrence, 

77 

purpose  of,  82 
sources  of  blood  in,  79 
theory  of,  80 

quantity  of  blood  lost  in,  78 
vicarious,  82 
Mesoblast,  94 

[Milk,  Alderney,  too  rich  for  young  in- 
fants, 547] 
artificial  human,  547 
ass's,  546 

cow's,  and  its  preparation,  546 
defective  secretion  of,  541 
excessive  secretion  of,  542 
goat's,  546 
means  of  arresting  the  secretion  of, 

540 

secretion  of,  after  delivery,  536 
Milk-fever,  525 
Miscarriage.     (See  Abortion.) 
Missed  labor,  181 
Moles,  232 

Monstrosity  (double),  357 
classification  of,  358 
mechanism  of  delivery  in,  358 
Mons  veneris,  41 
Montgomery's  cups,  90 
Morning  sickness,  135 
Mortality  of  childbirth,  523 


Mucous   membrane   of  uterus. 
Uterus.) 


(See 


NERVOUS  shock  after  delivery,  524 
Nervous  system,  changes  in,  during 

pregnancy,  131 

disorders  of,  in  pregnancy,  196 
excitability  of,  in  puerperal  wo- 
men, 555 

Neuralgia  in  pregnancy,  196 
Nipple,  70 
Nipples,  depressed,  541 

fissures  and  excoriations  of,  541 
Nursing.     (See  Lactation.) 
Nutrition  of  fetus,  116 
Nymphae.     (See  Labia  minora.) 


OBLIQUELY  contracted  pelvis,  373 
Obstetric  bag,  269 
Occipito-posterior  positions,  difficult  cases 

of,  307 
causes  of   face-to-pubis  delivery 

in,  307 

forceps  in,  308 
treatment  of,  308 
vectis  or  fillet  in,  308 
Omphalo-mesenteric  artery  and  vein,  96 
Opiates,  use  of,  after  delivery,  530 
Os  innominatum,  25 

Osteomalacia,  as  a  cause  of  deformity,  367 
Osteophytes,  formation  of,   during  preg- 
nancy, 131 

Os  uteri,  dilatation  of,  as  a  means  of  in- 
ducing labor,  439 
occlusion  of,  in  labor,  342 
Ovarian   pregnancy.     (See  Extra-uterine 

pregnancy.) 

tumor  in  pregnancy,  210 
Ovariotomy  in  pregnancy,  210 
Ovary;  63 

functions  of,  71 
structure  of,  63 
vascular  arrangements  of,  68 
Ovule,  68 

changes  in,  after  impregnation,  87 
changes  in,  when  retained  in  utero 

after  its  death,  232 
formation  of,  66 
Oxytocic  remedies,  330 


PAINS,  after-,  529 
false,  250 
irregular  and  spasmodic  as  a  cause  of 

protracted  labor,  329 
labor,  245 

Palpitation,  in  pregnancy,  191 
Pampiniform  plexus,  56 
Paralysis  in  pregnancy,  197 

from  embolism  of  the  cerebral  arteries, 

600 

from  embolism  of  the  main  arteries  of 
the  limb,  600 


INDEX. 


685 


Parovarimn,  59 
Parturient  canal,  axis  of,  37 
Pathology  of  decidua  and  ovum,  212 
Pelvis,    alterations    in,    articulations    of, 

during  pregnancy,  31 
anatomy  of,  25 
articulations  of,  28 
axes  of,  37 
Caesarean   section   in   deformities    of, 

385 

causes  of  deformity  of,  366 
comparative  estimate  of  turning  and 

forceps  in  deformity  of,  383 
craniotomy  in  deformity  of,  385 
diagnosis  of  deformity,  379 
deformities  of,  366 
development  of,  39,  40 
difference  according  to  race,  40 
difference  in  the  two  sexes,  32 
division  into  true  and  false,  32 
equally  contracted,  368 
equally  enlarged,  368 
forceps  in  deformity  of,  382 
induction  of  premature  labor  in  de- 
formity of,  385 
infantile,  39 
kyphotic,  374 
ligaments  of,  28 
masculine,  369 
mechanism  of  delivery  in  deformed, 

377 

movements  of  the  articulations  of,  30 
obliquely  contracted,  373 
planes  of,  37 
Robert's,  374 

soft  parts  connected  with,  40 
tumors  of,  375 
turning  in  deformity  of,  383 
undeveloped,  369 

Pelvic  cellulitis  and  peritonitis,  616 
etiology  of,  617 
importance  of  distinguishing 
the  two  forms  of  disease, 
617 
connection  with  septicaemia, 

618 

opening  of  abscess  in,  623 
prognosis  of,  622 
relative  frequency  of  the  two 

forms  of  disease,  619 
results  of  physical  examina- 
tion, 620 

seat  of  inflammation  in  cellu- 
litis, 618 

seat  of  inflammation  in  peri- 
tonitis, 619 
suppuration  in,  621 
symptomatology,  619 
terminations  of,  621 
treatment  of,  622 
two  distinct  forms  of  disease, 

617 
presentations,  286 

application  of  forceps  to  the  after- 
coming  head  in,  295 


Pelvic  presentations — 
causes  of,  286 
danger  to  child  in,  294 
diagnosis  of,  287 
frequency  of,  286 
management  of  impacted  breech 

in, '296 

mechanism  of,  289 
prognosis  in,  287 
treatment  of,  293 
Pelvimeters,  various  forms  of,  379 
Perchloride  of  iron,  injection  of,  in  post- 

partnm  hemorrhage,  414 
[Perforator,  Meigs's,  486] 

[rotary,  486] 
Perforators,  485 
Perineum,  411 

distension  of,  in  labor,  252,  275 

incision  of,  276 

laceration  of,  277 

relaxation  of,  275 

rigidity  of,  as  a  cause  of  protracted 

labor,  343 

Peritonitis,  pelvic.  (See  Pelvic  cellulitis.) 
Peritonitis,  puerperal.  (.See  Septicaemia.) 
Phlegmasia  dolens.  (See  Thrombosis, 

peripheral  venous.) 
Placenta,  100 

adhesion  of,  after  delivery,  407 

degeneration  of,  106 

detachment  of,  in  labor,  253 

expression  of,  280 

foetal  portion  of,  101 

form  of,  in  man  and  animals,  100 

functions  of,  106 

maternal  portion  of,  104 

minute  structure  of,  101 

pathology  of,  218 

sinus  system  of,  103 

sounds  produced  during  separation  of, 

147 

treatment  of  adherent,  411 
Placenta  membranacea,  218 
Placenta  praevia,  388 
causes  of,  388 

causes  of  hemorrhage  in,  391 
natural  termination  of  labor  in, 

393 
pathological  changes  of  placenta 

in,  392 

prognosis  in,  384 
sources  of  hemorrhage  in,  390 
summary   of  rules  of  treatment 

in,  398 

symptoms  of,  389 
treatment  of,  394 
turning  in,  455 
Placenta  succenturia,  218 
Placentitis,  219 
Plugging  of  vagina,  239 
Plural  births,  157,  353 

arrangement    of    placentae    and 

membranes  in,  159 
causes  of,  159 
diagnosis  of,  160 


636 


INDEX. 


Plural  births — 

relative  frequency  of,  in  different 

countries,  158 
sex  of  children  in,  158 
treatment  of,  354 
Pneumonia  in  pregnancy,  207 
"  Polar  globule,"  87 
[Polypus,  an  obstacle  to  delivery,  346] 
Position  of  cranium  in  head-presentation. 

(See  Head  presentation.) 
Post-partum    hemorrhage.      (See   Hemor- 
rhage.) 

Pregnancy,  123 
abnormal,  157 
alteration  of  color  of  vaginal  mucous 

membrane  as  a  sign  of,  142 
ballottement  as  a  sign  of,  141 
changes  in  the  blood  during,  129 
changes  in  the  liver,  lymphatics,  and 
spleen  during,  131 

in  the  urine  during,  132 
[complicated  with  ovarian  tumor,210] 
deposits  of  pigmentary  matter  during, 

138 

differential  diagnosis  of,  148 
dress  of  patient  in,  268 
duration  of,  151 
enlargement  of  abdomen  as  a  sign  of, 

139 
extra-uterine.       (See     Extra-uterine 

Pregnancy.) 

foetal  movements  in,  139 
formation  of  osteophytes  during,  131 
hypertrophy   of    the    heart    during, 

130 

in  cases  of  double  uterus,  57 
in  the  absence  of  menstruation,  135 
intermittent  uterine  contractions  as  a 

sign  of,  140 

[nitrous  oxide  safely  given  in,  190] 
ptyalism  in,  189 
prolapse  of  the  uterus  in,  201 
protraction  of,  153 
pruritus  in,  200 
quickening,  139 
sickness  of,  135 
signs  and  diagnosis  of,  133 
sounds  produced  by  the  fcotal  move- 
ments in,  147 
spurious,  150 

sympathetic  disturbances  of,  135 
uterine  fluctuation  in,  142 
vaginal  signs  of,  141 
pulsation  in,  141 
Premature  labor,  224 

history  of  the  operation  of  induc- 
tion of,  435 
indiiction  of,  435 

in  deformed  pelvis,  388 
injection  of  carbonic  acid  gas  as  a 

means  of  inducing,  441 
insertion  of  flexible  bougie  as  a 

means  of  inducing,  441 
objects  of  the  operation  of  induc- 
tion of,  435 


Premature  labor — 

oxytocics  as  a  means  of  inducing, 

438 

period  for  the  induction  of,  in  de- 
formed pelvis,  387 
precautions  as  regards  the  child 

in  the  induction  of,  442 
puncture  of  the  membranes  as  a 

means  of  inducing,  437 
separation  of  the  membranes  as  a 

means  of  inducing,  440 
vaginal  and  uterine  douches  as  a 

means  of  inducing,  440 
Pressure  as  a  means  of  inducing  uterine 

contractions,  332 
mode  of  applying,  333 
Prolapse  of  umbilical  cord.     (See  Umbili- 
cal cord.) 

Ptyalism  in  pregnancy,  189 
Piierperal  convulsions.     (See  Eclampsia.) 
fever.     (See  Septicaemia.) 
mania.     (See  Insanity.) 
state,  523 

after-treatment  in,  533 
diet  and  regimen  in,  531 
diminution  of  uterus  in,  526 
importance  of  prolonged  rest  in, 

532 

secretions  and  excretions  in,  525 
temperature  in,  525 

Pulmonary  arteries,  anatomical  arrange- 
ment of,  as  favoring  thrombosis,  597 
Pulse,  state  of,  after  delivery,  524 


rvUICKENING,  151 

v£     [Quinine  as  an  oxytocic,  330] 


RACE  as  influencing  the  size  of  the  foetal 
skull,  112 

Recto-vaginal  fistula,  427 
Respiration  of  foetus,  118 
Respiratory  chamber,  86 
Retroversion  of  the  gravid  uterus,  203 
Rickets  as  a  cause  of  pelvic  deformity,  367 
Rosenmiiller,  organ  of.    (See  Parovarium.) 
Round  ligaments  of  the  uterus,  60 
Rupture  of  uterus.     (See  Uterus.) 


SACRUM,  anatomy  of,  27 
mechanical  relations  of,  27 
Salivation  in  pregnancy,  189 
Scarlet  fever  affecting  the  foetus,  224 
in  pregnancy,  207 
in  the  puerperal  state,  578 
Scybalae  in  the  rectum  obstructing  labor, 

347 

Septicaemia  (puerperal),  570 
bacteria  in,  581 
channels  of  diffusion  in,  582 

through  which  septic  matter  may 

be  absorbed,  574 
cold  in  treatment  of,  592 


INDEX. 


637 


Septicaemia — 

conduct  of  practitioner  in  regard  to, 

581 

contagion   from   other   puerperal  pa- 
tients as  a  cause  of,  579 
description  of,  586 
division  into  auto-genetic  and  hetero- 

genetic  forms,  575 
epidemics  of,  572 
history  of,  571 
importance  of  antiseptic  precautions 

in,  581 
influence  of  cadaveric  poison  as  a  cause 

of,  576 

influence  of  zymotic  diseases  in  caus- 
ing, 577 
its    connection  with  pelvic   cellulitis 

and  peritonitis,  618 
local  changes  in,  582 
mode  in  which  the  poison  may  be  con- 
veyed to  patients  in,  580 
nature  of  septic  poison,  581 
pathological  phenomena  in,  583 
pysemic  forms  of,  585 
sources  of  auto-infection  in,  575 

of  hetero-infection,  575 
symptoms  of  the  intense  forms,  586 
theory  of  an  essential  zymotic  fever, 

573 

of  identity  with   surgical   septi- 
caemia, 573 
of  local  origin,  572 
transfusion  of  blood  in,  514 
treatment  of  a,  588 
Warburg's  tincture  in  the  treatment 

of,  591 

Sex,  discovery  of,  of  foetus  during  preg- 
nancy, 143 
of  foetus  as  influencing  the  size  of  the 

skull,  112 

Shoulder  presentations,  309 
diagnosis  of,  312 
division  of,  310 
mechanism  of,  314 
prognosis  and  frequency  of,  312 
spontaneous  version  in,  314 
treatment  of,  321 
[Siamese  Twins,  how  born,  358] 
Sickness  of  pregnancy,  135 
[Silver  uterine  sutures,  509] 
[Sleep  on  inclined  plane,  for  relief  of  dys- 
pnoea of  pregnancy,  191] 
Smallpox  affecting  the  foetus,  223 

in  pregnancy,  207 

Smith's,  Tyler,  theory  of  labor,  243 
Spondylolithesis,  371 
Spontaneous  evolution,  315 

version,  313 

Spurious  pregnancy,  150 
diagnosis  of,  151 
symptoms  of,  150 
Symphyseotomy,  510 
Syncope  during  or  after  labor,  607 

in  pregnancy,  191 
Syphilis  affecting  the  foetus,  224 


Syphilis — 

as  a  cause  of  abortion,  233 

in  pregnancy,  208 

Super-fecundation  and  super-footation,  1G1 
Sutures  of  foetal  head,  110 


^TEMPERATURE  after  delivery,  524 
_L      [Thomas's  operation,  171] 
Thrombosis  (peripheral  venous),  609 

changes  in  thrombi  in,  618 

condition  of  the  affected  limb,  610 

detachment  of  emboli  in,  614 

history  and  pathology  of,  611 

progress  of  the  disease,  611 

symptoms  of,  610 

treatment  of,  614 
(puerperal),  594 

arterial  thrombosis  and  embolism, 
605 

cardiac  murmur  in  pulmonary, 
602 

cases  illustrating  recovery  from 
pulmonary,  600 

causes  of  death  in  pulmonary, 
603 

clinical  facts  in  favor  of  pulmo- 
nary, 597 

conditions  which  favor  throm- 
bosis in  the  puerperal  state, 
595 

distinction  between  thrombosis 
and  embolism,  596 

phlegmasia  dolens  a  consequence 
of,  594 

post-mortem  appearance  of  clots 
in  pulmonary,  603 

question  of  primary  thrombosis 
in  the  pulmonary  arteries,  611 

question  of  recovery  from  pulmo- 
nary, 596 

symptoms  of  arterial,  605 

of  pulmonary  obstruction  in, 
599 

treatment  of  arterial,  607 

of  pulmonary,  604 
Thrombus.     (See  Hsematocele.) 
Toothache  in  pregnancy,  190 
Transfusion  of  blood,  514 

addition  of  chemical  reagents  to 
prevent  coagulation  of  fibrine, 
517 

cases  suitable  for  the  operation, 
519 

dangers  of  the  operation,  519 

defibrination  of  blood  in,  518 

difficulties  of  the  operation,  516 

effects  of  successful  transfusion, 
522 

history  of  the  operation,  514 

immediate  transfusion,  517 

method  of  injecting  deflbrinated 
blood,  522 

method  of  performing  immediate 
transfusion,  520 


638 


IN1>EX. 


Transfusion  of  blood — 

method  of  preparing  defibrinated 

blood,  521 

nnturo  and  object  of  the  opera- 
tion, 515 

secondary  effects  of,  522 

statistical  results  of,  519 

Tropics,  influence  of  residence  in,  on  labor, 

327 
Trunk,    presentation   of.     (See    Shoulder 

presentations.) 
Tumors,  diagnosis  of  uterine  and  ovarian, 

149 
foetal,  226 

obstructing  labor,  364 
Tunica  albuginea,  64 
Turning,  442 

anaesthesia  in,  446 
by  combined  method,  446 
by  external  manipulation  only,  444 
cases  suitable  for  the  operation,  444 
for    operating   by   combined 

method,  445 
cephalic,  446 

choice  of  hand  to  be  used.  448 
history  of  the  operation,  442 
in  abdomino-anterior  positions,  456 
in  deformed  pelvis,  383 
in  placenta  prsevia,  396,  455 
method  of  cephalic,  443 

of  performing  by  external  manip- 
ulation, 445 
of  podalic,  447 
object  and  nature  of  the  operation, 

443 
period  when  the  operation  should  be 

performed,  448 
podalic,  447,  451 
position  of  patient  in,  447 
statistics  and  dangers  of,  44 
value  of  anaesthetics  in  difficult  cases 

of,  457 

Twins.     (See  Plural  births.) 
conjoined,  356 
locked,  355 


UMBILICAL  cord,  106 
knots  of,  107,  227 
ligature  of,  277 
pathology  of,  221 
prolapse  of,  319 
causes  of,  321 
diagnosis  of,  321 
frequency  of,  319 
prognosis  of,  420 
postural  treatment  of,  322 
reposition  of,  323 
Umbilical  souffle,  145 

vesicle,  95 

["  Untimely  ripped"  in  Shakespeare,  500] 
Urachus,  97 

Uraemia,  in  connection  with  eclampsia,  522 
in  connection  with  puerperal  insanity, 
563 


Urethra,  43 

Urine,  changes  in,  during  pregnancy,  132 

retention  of,  after  delivery,  530 
Uterine   fluctuation,   as    a  sign   of   preg- 
nancy, 142 

souffle,  145 

Utero-sacral  ligaments,  61 
Uterus,  47 

analogy  of  interior  of,  after  delivery, 
and  stump  of  an  amputated  limb, 
93 

anomalies  of,  57 

arrangement  of  muscular  fibres  of,  52 

axis  of,  during  pregnancy,  125 

changes  in  cervix  during  pregnancy, 
126,  141 

changes  in  form  and  dimensions  of, 
during  pregnancy,  123 

changes  in  mucous  membranes  of, 
after  delivery,  527 

changes  in  mucous  membranes  of, 
after  impregnation,  89 

changes  in  tissues  of,  during  preg- 
nancy, 128 

changes  in  the  vessels  of,  after  de- 
livery, 527 

congestive  hypertrophy  of,  149 

contractions  of,  in  labor,  245 

dimensions  of,  49 

diminution  in  size  of,  after  delivery, 
526 

distension  of,  as  a  cause  of  labor,  243 

distension  of,  by  retained  menses,  148 

fatty  transformation  of,  after  delivery, 
527 

intermittent  contractions  of,  during 
pregnancy,  140 

internal  surface  of,  50 

inversion  of,  429 

differential  diagnosis  of,  430 

production  of,  430 

results  of  physical  examination 

in,  430 

symptoms  of,  429 
treatment  of,  432 

ligaments  of,  59 

lymphatics  of,  56 

malposition  of,  as  a  cause  of  protracted 
labor,  328 

mode  of  action  in  labor,  245 

mucous  membrane  of,  53 

muscular  fibres  of,  52 

nerves  of,  57 

[persistent  intermittent  contraction 
of,  141] 

regional  division  of,  50 

relations  of,  48 

retroversion  of  gravid,  204 

[rupture  of,  gastrotomy,  426] 

size  of,  at  various  periods  of  preg- 
nancy, 124 

state  of,  in  protracted  labor,  327 

structures  composing,  51 

rupture  of,  419 

alterations  of  tissues  in,  421 


039 


Uterus,  rupture  of — 

causes  of,  421 

comparative    result    of     various 
methods  of  treatment  in,  426 

prognosis  of,  424 

seat  of  laceration  in,  420 

symptoms  of,  423 

treatment  of,  424,  427 
utricular  glands  of,  53 
vessels  of,  56 
weight  of,  after  delivery,  527 


VAGINA,  45 
bands  and  cicatrices  of,  obstructing 

delivery,  343 

contraction  of,  after  delivery.  526 
lacerations  of,  427 
orifice  of,  43 
structure  of,  46 

[Vaginismus,  with  double  vagina,  58] 
Varicose  veins  in  pregnancy,  201 
Vectis,  482 

action  of,  482 

cases  in  which  it  is  applicable,  483 
Veins,  entrance  of  air  into,  as  a  cause  of 
sudden  death  after  delivery,  608 


Venesection  for  rigidity  of  cervix,  340 

Version.     (See  Turning.) 

Vesico-uterine  ligaments,  61 

Vesico-vaginal  fistula,  427 

Vestibule,  42 

Vicarious  menstruation,  82 

Vomiting  in  pregnancy,  184 

Vulva,  41 

condition  of,  after  delivery,  528 
oedema  of,  obstructing  labor,  348 
vascular  supply  of,  45 

Vulvo-vaginal  glands,  44 


WARBURG'S  tincture,  591 
Weaning.     (See  Lactation.) 
Wet-nurse,  selection  of,  537 
Wolffian  bodies,  57,  108 
Wounds  of  the  fetus,  226 


ZONA  pellucida,  68 
Zymotic  disease,  affecting  the  fetus, 

223 
as  a  cause  of  septic:emia,  577 


O. 

(LATE  LEA  *  BLANCHARD'S) 


OF 

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(For  THK  "OBSTETRICAL  JOURNAL,"  see  p.  23.) 


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EDITED  BY  ISAAC  HAYS,  M.D.,  AND  I.  MINIS  HAYS,  M.D., 

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leading  organ  of  medical  progress: — 

This  is  universally  acknowledged  as  tbe  leading!  The  Philadelphia  Medical  and  Physical  Journal 
American  Journal,  and  has  been  conducted  by  Dr.  |  issued  its  first  number  in  1820,  and  after  a  brilliant 
Hays  alone  until  1869,  when  his  son  was  asKociated  I  career,  was  succeeded  in  1827  by  the  American 
with  him.  We  quite  agree  with  the  critic,  that  this  |  Journal  of  the  Medical  Sciences,  a  periodical  of 


journal  is  second  to  none  in  the  language,  and  cheer- 
fully accord  to  it  the  first  place,  for  nowhere  shall 
we  find  more  able  and  more  impartial  criticism,  and 
nowhere  such  a  repertory  of  able  original  articles. 
Indeed,  now  that  the  '•  British  and  Foreign  Medico- 
Chirurgical  Review"  has  terminated  its  career,  the 
American  Journal  stands  without  a  rival. — London 
Med.  Times  and  Gazette,  Nov.  24,  1877. 

The  present  number  of  the  American  Journal  is  an 
exceedingly  good  one,  and  gives  every  promise  of 
maintaining  the  well-earned  reputation  of  the  re  view 
Our  venerable  contemporary  has  our  best  wishes, 
and  we  can  only  express  the  hope  that  it  may  con- 
tinue its  work  with  as  much  vigor  and  excellence  for 
the  next  fifty  years  as  it  has  exhibited  in  the  past. 
— London  Lancet,  Nov.  24,  1S77. 


world-wide  reputation  ;  the  ablest  and  one  of  the 
oldest  periodicals  in  the  world — a  journal  which  has 
an  unsullied  record. — Gross's  History  of  American 
Med.  Literature,  1876. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. —  Boston  Med.  and 
Surg.  Journal,  Oct.  1877. 

This  is  the  medical  journal  of  our  country  to  which 
the  American  physician  abroad  will  point  with  the 
greatest  satisfaction,  as  reflecting  the  state  of  medical 
culture  in  his  country.  For  a  great  many  years  it 
ha'*  been  the  medium  through  which  our  ablest  writ- 
ers have  made  known  their  discoveries  and  observa- 
tions — Address  of  L.  P.  Yandell,  M.D.,  before  Inter- 
national Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher 
in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES"  has 
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II. 

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is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "LIBRARY  DEPARTMENT"  is  devoted  to  publishing  standard  works  on  the 
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many  other  volumes  of  the  highest  reputation  and  usefulness.  With  July,  1878,  was 
commenced  the  publication  of  "LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM,"  by 
J.  M.  CHARCOT,  Professor  in  the  Faculty  of  Medicine  of  Paris,  translated  from  the 
French  by  GEOHGB  SIGERSON,  M.D.,  Lecturer  on  Biology,  etc.,  Catholic  Univ.  of 

*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  Publisher. 


HENRY  C.  LEA'S  PUBLICATIONS — (Am.  Journ.  Med.  Science*).         3 

Ireland  (see  p.  17),  which  will  be  continued  to  completion  during  1879.  New  sub- 
scribers, commencing  with  January,  1879,  can  procure  the  previous  portion  by  a 
remittance  of  50  cents,  if  promptly  made. 

The  "NEWS  DEPARTMENT"  of  the  "MKDICAL  NEWS  AND  LIBRARY"  presents  the 
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A  new  and  attractive  feature  of  this  will  be  found  in  an  elaborate  series  of  ORIGINAL 
AMERICAN  CLINICAL  LECTURES,  specially  contributed  to  the  News  by  gentlemen  of 
the  highest  reputation  in  the  profession  throughout  the  United  States.  During  lb7B 
there  have  appeared  Lectures  by 

S.  D.  GROSS,  M.D.,  Prof,  of  Surgery,  Jefferson  Med.  Coll.,  Philada. 

T.  GAILLARD  THOMAS,  M.D.,  Prof.  Obstetrics.  &c.,  Coll.  Phys.  and  Surg.,  N.  Y. 

WILLIAM  PEPPER,  M.D..  Prof.  Clin.  Medicine,  Univ.  of  Penna. 

LEWIS  A.  SAY  RE.  M.D.,  Prof.  Orthopedic  Surg.,  Bellevue  Hosp.Med.  Coll..  NY. 

ROBERTS  BARTHOLOW,  M.D.,  Prof.  Theory  and  Practice  of  Med.,  Med.  Coll.  of  Ohio. 

T.  G.  RICHARDSON,  M.D.,  Prof.  Genl.  and  Clin.  Surg.,  Univ.  of  La.,  New  Orleans-. 

S.  W.  GROSS,  M.D.,  Surg.  to  Philada.  Hospital. 

F.  PEYRE  PORCHER,  M.D.,  Prof,  of  Mat.  Med.  and  Clin.  Medicine,  Med.  Coll.  of  S.  C. 

WILLIAM  GOODKLL,  M.D..  Prof.  Clin.  Gynrecology,  Univ.  of  Penna. 

N.  S.  DAVIS,  M.D..  Prof.  Prin  and  Prac.  of  Med.,  Chicago  Med.  Coll. 

W.  H.  VAN  BUREN,  M.D.,  Prof.  Surgery,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 
To  be  followed  by  others  of  similar  value  from 

AUSTIN  FLINT,  M.D.,  Prof.  Prin.  and  Prac.  of  Med. .Bellevue  Hosp.  Med.  Coll..  N.Y. 

FORDYCE  BARKER.  M.D.,  Prof.  Clin.  Midwifery,  &c.,  Bellevue  Hosp.  Med.  Coll.,  N.Y. 

L.  A.  DUHRING,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Skin,  Univ.  of  Penna. 

THEOPHILUS  PARViN.M.D.,Prof.  Obstetrics, &c..  Coll.  Phys.  and  Surg.,  Indianapolis. 

J.  P.  WHITE,  M.D.,  Prof,  of  Obstetrics,  &c.,  Univ.  of  Buffalo. 

JOHN  ASHHURST,  Jr.,  M  D.,  Prof,  of  Clin.  Surg.,  Univ.  of  Penna. 

D.  WARREN  BRICKELL,  M.D.,  Prof.  Obstetrics,  &c..  Charity  Hosp.  Med  Coll.,  N.  0. 

J.  LEWIS  SMITH,  M.D.,  Clin.  Lee.  on  Dis.  of  Chil.,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 

WILLIAM  F.  NORRIS,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Eye,  Univ.  of  Penna. 

P.  S.  CONNER,  M.D.,  Prof,  of  Anat.  and  Clin.  Surgery,  Med.  Coll.  of  Ohio,  Cin. 

S.  WEIR  MITCHELL,  M.D.,  Phys.  to  the  Infirmary  for  Nervous  Diseases.  Philada. 

J.  M.  DACOSTA,  M.D.,  Prof.  Prin.  and  Prac.  of  Med.,  Jeff.  Med.  Coll.,  Philada. 

THOMAS  G.  MORTON,  M.D.,  Surgeon  to  Penna.  Hospital,  Philada. 

F.  J.  BUMSTEAD,  M.D.,  late  Prof,  of  Venereal  Dis.,  Coll.  Phys.  and  Surg.,  N.  Y. 

J.  H.  HUTCHINSON,  M.D.,  Physician  to  Penna.  Hospital. 

CHRISTOPHER  JOHNSON,  M.D.,  Prof,  of  Surgery,  Univ.  of  Md.,  Baltimore. 

WILLIAM  THOMSON,  M.D.,  Lecturer  on  Ophthalmology,  Jeff.  Med.  Coll.,  Philada. 

With  contributors  such  as  these,  representing  every  portion  of  the  United  States, 
the  publisher  feels  safe  in  promising  to  the  subscriber  a  series  of  practical  lectures 
unsurpassed  in  variety,  interest,  and  value. 

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III. 

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pages,  thus  furnishing  in  the  course  of  the  year  about  six  hundred  pages.  The  aim 
of  the  "  ABSTRACT"  is  to  present— without  duplicating  the  matter  in  the  "JOURNAL" 
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has  been  carried  out  it  is  sufficient  to  state  that  during  the  year  1878  it  contained 

3O  Articles  on  A.niitoni'jj  and  l*ln/si(>l<>r/t/. 

fi<>          "  tl    Mnteria  Medicit  and  Thorapeutlca,  I 

230         "  "    JUrdicinc. 

151          "  '•    Nurffrry. 

"    JHid.ivi/'vry  tint?  Gyncecologif. 

1'J          "  "    Medical  Jurisprudence  and  Toxicology — 

making  in  all  558  articles  in  a  single  year. 

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JOURNAL  OF  THE  MEDICAL  SCIENCES"  and  the  "MEDICAL  NEWS  AND  LIBRARY,"  makin>' 
in  all  about  TWENTY-ONE  HUNDRED  pages  per  annum,  the  whole  free  of  postage,  for 
Six  DOLLARS  a  year,  in  advance. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confiJeutly  anticipates  the  friendly 


HENRY  C.  LEA'S  PUBLICATIONS — (Dictionaries). 


aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  "AMERICAN  MEDICAL  JOURNAL"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing  of  cheapness  never  heretofore  attempted. 

PREMIUM  FOE  OBTAINING  NEW  SUBSCRIBERS  TO  THE  "JOURNAL." 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1879,  one  of 

which  must  be  for  a  new  subscriber,  will  receive  as  a  PREMIUM,  free  by  mail,  a  copy  of 

"  HOLDKN'S  LANDMARKS.  MEDICAL  AND  SURGICAL"  (for  advertisement  of  which  se'e  p. 

6),  or  of  FOTHEKGILL'S  "  ANTAGONISM  OF  MEDICINES"  (see  p.  1C),  or  of  "  BROWNE  ON 

TFiE  USE  OF  THE  OPHTHALMOSCOPE"  (S6C  p.  2i»),  Or  Of  "  FlJNT'sEsSAYS  ON  CONSERVATIVE 

MEDICINE"  (see  p.  15),  or  of  "STURGES'S  CLINICAL  MEDICINE"  (see  p.  14),  or  of  the 
new  edition  of  "SWAYNE'S  OBSTETRIC  APHORISMS"  (see  p.  21),  or  of  "TANNER'S 
CLINICAL  MANUAL"  (see  p.  5),  or  of  "CHAMBERS'S  RESTORATIVE  MEDICINE"  (see  p. 
18),  or  of  "WEST  ON  NERVOUS  DISORDERS  OF  CHILDREN"  (see  p.  20). 

%*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
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Ilif  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
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"JOURNAL"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  iu  REGISTERED 
letters.  Address, 

HENRY  C.  LEA,  Nos.  706  and  708  SANSOM  ST.,  PHILADELPHIA,  PA. 

flUNGLISON  (ROBLEY],  M.D., 

"^^  Late  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  doll-eye,  Philadelphia. 

MEDICAL  LEXICON;  A  DICTIONARY  OP  MEDICAL  SCIENCE:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes  ;  so  as  to  constitute  a  French  as  well  as 
English  Medical  Lexicon.  A  New  Edition.  Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.  By  RICHARD  J.  DUNGLISON,  M.D.  In  one  very  large  and  hand- 
some  royal  octavo  volume  of  over  1100  pages.  Cloth,  $6  50;  leather,  raised  bands,  $7  50. 
(Just  Issued.) 

The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  under  each,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  theimmense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en  • 
viable  reputation.  During  the  ten  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenjlatnreoftbe  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
ofthe  past,  and  up  to  the  time  of  his  death  the  authorlabored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  has  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typ>graphical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, Dr.  Richard  J.  Dungli.oon,  having  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it.  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  edit  it  as  a  work  ofthe  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  groove*  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
present  edition. — Phila.  Mtd.  Time*,  Jan.  3, 1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent is  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  sine  qua  nun.  In  a  i 


science  so  extensive,  and  with  such  collaterals  as  medi- 
cine, it  is  as  much  a  necessity  also  to  the  practising 
physician.  To  meet  the  wants  of  students  and  most 
physicians,  the  dictionary  must  be  condensed  while 
jomprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indications  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  additions  been 
•so  great.  More  than  six  thousand  new  subjects  and  t  erms 
have  been  added.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 
"that  the  work,  which  possesses  for  him  a  filial  as  well 
»s  an  individual  interest,  will  be  found  worthy  a  con- 
tinuance of  the  position  so  long  accorded  to  it  as  • 
standard  authority." — Cincinnati  Clinic,  Jan.  10. 1874. 
It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references.— London  Medical  Qatette. 


HENRY  C.  LEA'S  PUBLICATIONS— (Manuals'}. 


A  CENTURY  OF  AMERICAN  MEDICINE,  177B-187G.  By  Doctors  K.  H. 
-*-*-  Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thomas,  and  J.  S.  Billings.  In  one  verj  hand- 
some 12mo.  volume  of  about  350  pages  :  cloth,  $2  25.  (Just  Reti/iy.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Sciences- during  the 
year  1876.  As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle- 
men of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
come it  in  a  form  adapted  for  preservation  and  reference. 


fJOBLYN  (RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  ISAAC  HAYS, 
M.  D.,  Editor  of  the  "  American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  cloth,  $1  50;  leather,  $2  00 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Med.  and,  Surg.  Journal.  

T?OD  WELL  (G.  F.),  F.R.A.S.,  £«. 

A  DICTIONARY  OF  SCIENCE :  Comprising  Astronomy,  Chem- 

istry,  Dynamics,  Electricity.  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations  :  cloth,  $5.  >>*':" 


(JOHN),  M.D.,  and     VMITH  (FRANCIS  G.),  M.D., 

Prof  .of  the  Institutes  of  Medicine  inthe  Univ.of  Pennt . 

AN    ANALYTICAL    COMPENDIUM   OF    THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12im. 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 

JJARTSHORNE  (HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    O»F    THE    MEDICAL    SCIENCES;    containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine, 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  en 
wood.  Cloth,  $4  25  ;  leather,  $5  00.  (Lately  Issued.} 


dents,  but  to  many  others  who  may  desire  to  refresh 
their  memories  with  the  smallest  possible  expendi- 
ture of  time. — tf.  Y.  Med.  Journal,  Sept.  1874. 

The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 

Tnis  is  the  best  book  of  its  kind  that  we  have  evtr 
examined.  It  is  an  honest,  accurate,  and  concise 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 
rough as  to  render  it, so  far  as  it  goes,  entirely  trust- 
worthy. If  students  must  have  a  conspectus,  they 
will  he  wise  to  procure  that  of  Dr.  Hartshorne. — 
Detroit  Rev.  of  Med  and  P/iarm.,  Aug.  1874. 


We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  are  acquainted. 
It  embodies  iua  condensed  form  all  recent  contribu- 
tions to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed. — Charleston  Med.  Journ.,  April,  1875.  ' 

The  work  is  intended  as  an  aid  to  the  medical 
stulent,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  full  compi- 
lation of  facts,  the  perspicuity  aud  terseness  ot'lau- 
guage,  aad  the  clear  aud  instructive  illustrations 
in  some  parts  of  the  work  — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 
The  volume  will  be  found  useful,  not  only  to  stu- 

TUDLOW  (J.L.),  M.D. 
A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12ino.  volume  of  816  large  pages,  cloth,  $3  25 ;  leather,  $3  75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 

/TANNER  (THOMAS  HAWKES),  M.D.,  §-c. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAG- 

NOSIS.  Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
TILBURY  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospita  , 
Ac.  In  one  neat  volume  small  12mo.,  of  about  375  prtges,  cloth.  $150. 

***  On  page  4,  it  will  be  seen  that  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES." 


HENRY  C.  LEA'S  PUBLICATIONS—  (A natomy'). 


(HENRY),  F.R.S., 

Lecturer  on  Anatomy  at  St.  Oeorge'g  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  CARTER,  M.D.,  and  Dr.  WESTMACOTT.  The  Dissectionsjointly  by  the  AUTHOR  and 
Dr.  CARTER.  With  an  Introduction  on  General  Anatomy  and  Development  by  T. 
HOLMKS,  M.A.,  Surgeon  to  St.  George's  Hospital.  A  new  American,  from  the  eighth 
enlarget  and  improved  London  edition.  To  which  is  added  "  LANDMARKS,  MEDICAL  AND 
SURGICAL,"  by  LUTHER  HOLDEN,  F.R  C.S.,  author  of  "  Human  Osteology,"  "A  Manual 
of  Dissections,"  etc.  In  one  magnificent  imperial  octavo  volume  of  983  pages,  with 
522  large  and  elaborate  engravings  on  wood.  Cloth,  $6;  leather,  raised  bands,  $7. 
(Just  Ready.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extendedrange  ofsubjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  but 
also  the  application  of  those  details  in  the  practice  of  medicine  and  surgery,  thusrendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
which  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  has  seemed 
requisite  to  maintain  its  reputation  as  a  complete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
— which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 

to  consult  his  fcooks  on  anatomy.  The  work  is 
simply  indispensable.  e.--pecially  this  present  Amer- 
ican edition.—  Va.  Med.  Monthly,  Sept.  187P. 

The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  American  students, 
who  find  in  it  a  comprehensive  chapter  on  minute 
anatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  vie  v,  in  the  valu- 
able section  by  Mr  Holden.  is  all  that  will  be  essen- 
tial to  them  in  practice. — Ohio  Medical  Recorder, 
Aug  1878. 

It  is  difficult  to  speak  in  moderate  terms  of  this 
new  edition  of  "Gray."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  men  who  have  successively  revised  the 
eight  editions  through  which  it  has  passed,  would 
seem  to  leave  nothing  for  future  editors  to  do.  The 
addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofore  to  the  student.  As 
regards  completeness,  ease  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
dent should  enter  a  medical  school  without  it ;  no 
physician  can  afford  to  have  it  absent  from  hi» 
library  —St.  Louis  Olin.  Record,  Sept.  1878. 


The  recent  work  of  Mr  Holden,  which  was  no- 
ticed by  us  on  p.  53  of  this  volume,  has  been  added 
as  an  appendix,  so  that,  altogether,  this  is  the  moit 
practical  and  complete  anatomical  treatise  available 
to  American  students  and  physicians.  The  former 
finds  in  it  the  necessary  guide  in  making  dissec- 
tions ;  a  very  comprehensive  chapter  on  minute 
anatomy  ;  and  about  all  that  can  be  taught  him  on 
general  and  special  anatomy;  while  the  latter,  in 
its  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  edition  of  Mr  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice — New  Remtd >es,  Aug  1S78. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  us  a 
text-book  or  a  genera)  reference  hook  on  anatomy 
to  be.  The  American  publisher  deserves  the  ihanks 
of  the  profession  for  appending  the  recent  work  of 
Mr.  Holden,  "Landmarks,  Medical  and  Surgical," 
which  has  already  been  commended  as  a  separate 
book.  The  latter  work— treating  of  topographical 
anatomy— has  become  an  essential  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distinguished  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anything  further  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  in  this  country,  and  the  daily  refer- 
ence book  of  every  practitioner  who  has  occasion 


ALSO  FOR  SALE  SEPARATE — 

HOLD  EN  (LUTHER),  F.R.C.S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals. 


LANDMARKS,  MEDICAL  AND 

Ed.  In  one  handsome  volume,  royal  12mo 
The  title  of  this  book  is  very  suggestive  of  its 
practical  value,  while  the  perusal  of  the  work  itself 
Terifles  the  most  extravagant  expectations.  The 
object  of  the  author  has  been  to  collect  in  compact 
form  the  landmarks,  or  surface-marks  of  the  different 
parts  of  the  bodv,  aiid  indicate  their  relation  to  the 
deeper-seated  parts.  The  value  of  thissortof  know- 
ledge to  the  physician,  but  especially  to  the  surgeon 
who.  with  anaioinical  eye,  can  make  the  tissues 


SURGICAL.    From  the  2d  London 

.,  of  128  pages  :  cloth,  88  cents.    (Now  Ready.) 

transparent  before  him,  is  incalculable.  The  map- 
ping out  ol  the  human  body  is  one  which  is  most  in- 
structive to  the  practical  man,  and  he  is  enabled, 
after  considerable  experience,  to  have  landmarks 
of  his  own;  but  in  the  little  work  before  us  this 
knowledge  is  systematized  in  such  an  intelligible 
manner  as  to  place  it  within  the  reach  of  all.  It  is 
one  of  the  mostintereMiuglittle  works  we1  have  seen 
for  a  long  time. — A'.  Y.  Mud.  Record,  May  11,  1878. 


HENRY  C.  LEA'S  PUBLICATIONS — (Anatomy'). 


T 


A  LLEN  (HARRISON),  M.D. 

-£*-  Pri'f tenor  of  Physiology  in  thf.  Univ.  of  Pa. 

A  SYSTEM  OP  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Students  of  Medicine.    With  ;m 
Introductory  Chapter  on  Histology.  By  E.  0.  SHAKESPEARE,  M  D  ,  Ophthalmologist  to  the 
Phila.  Hosp.    In  one  large  and  handsome  quarto  volume,  with  several  hundred  original 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  text.      (Preparing-.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  h;is 
sought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clear  and  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  the  significance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self  evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.   No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissections,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "  Gray, "  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

TFL LIS  (GEORGE   VINE R), 

-U  Emeritus  Prof esxor  rj  Anatomy  in  University  College,  London. 

DEMONSTRATIONS  IN  ANATOMY;  Being  a  Guide  to  the  Know- 

ledge  of  the  Human  Body  by  Dissection.  By  GEORGE  VINKR  ELLIS,  Emeritus  Professor 
of  Anatomy  in  University  College,  London.  From  the  Eighth  and  Revised  London 
Edition.  In  one  very  handsome  octavo  volume  of  orer  700  pages,  with  256  illustrations. 
(Nearly  Ready.) 

This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
and  the  favorite  guide  in  the  dissecting-room,  us  is  attested  by  the  numerous  editions  through 
which  it  has  passed.  In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organs,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

ffTILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  GOBRECMT,  M.D  ,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  600  large  pages  ;  cloth,  $4  ;  leather.  $5. 

fJEATH  (CHRISTOPHER),  F.R.C.S., 

t~*-  Teacher  of  Operative  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissections.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  KEEN 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia! 
In  one  handsome  royal  12mo. volume  cf  678  pages,  with  247  illustrations.' Cloth,  $3  60  • 
leather,  $4  00.  _ 

VMITH  (HENRY H.),  M.D.,         and  JJORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna.,  Ac.  "     LateProf.  of  Anatomy  in  the  Univ.  ofPenna. 

AN    ANATOMICAL    ATLAS,  illustrative   of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  cloth,  with  about  six  hundred  and 
fifty  beautilul  figures.  $4  60. 

T>ELLAMY(E.),F.R.C.S.  ~ 

THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOMY:  A  Text- 

Book  for  Students  preparing  for  their  Pass  Examination.  With  engravings  on  wood.  In 
one  handsome  royal  12mo.  volume.  Cloth.  $2  25.  (Lately  Published. ) 

riLELAND  (JOHN),  M.D.,  ~ 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Galway. 

A   DIRECTORY  FOR  THE    DISSECTION  OF  THE  HUMAN  BODY. 

In  one  small  volume,  royal  I  2mo.  of  182  pages  :  cloth,  $1  25.     (Just  Issued.) 
&CHAFER  (EDWARD  ALBERT),  M.D., 

*-J  Assistant  Profenor  of  Phy  urology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.  In  one  handsome  royal  12ino.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.  (Just  Issued.) 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  r«vji»(>d  and 
modified  In  il  vole.  8vo.,  of  over  1000  pages. 
with  320  wood-outs  ;  cloth,  96  00. 


SHARPEY  AND  QUAIN'S  HUMAN  ANATOMY. 
Revised,  by  JOSEPH  LKIDT,  M  D.,  Prol'  of  Asat. 
in  Uuiv.  of  Penn.  In  two  octavo  vols.  of  about 
1300  pages,  with  511  illuitrationi.  Cloth,  $6  Of  . 


8 


HENRY  C.  LEA'S  PUBLICATIONS — (Physiology). 


(JARP ENTER  (  WILLIAM  B.),  M.D.,  F.R.S.,  F.G.S.,  F.L.S., 

Registrar  to  University  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HENRY?OWER, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.     Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  FRANCIS  G.  SMITH,  M.D.,  Professor  of  the  Institutes  of  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  3  73  engravings  on  wood;  cloth,  $5  50  ;  leather,  $6  50.    (Just  Issued.) 
Thegreat  work,  the  crowning  labor  of  the  distinguished  author,  and  through  which  so  many 
generations  of  students  have  acquired  their  knowledge  of  Physiology, has  been  almost  meta- 
morphosed in  the  effort  to  adopt  it  thoroughly  to  the  requirements  of  modern  science.    Since 
the  appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced 
hand  of  Mr.  Power,  who  has  modified  and  enlarged  it  so  as  to  introduce  all  that  is  important 
in  the  investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlarge- 
ment of  about  one-fourth  in  the  text.   The  series  of  illustrations  has  undergone  a  like  revision, 
a  large  proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased 
to  nearly  four  hundred.     The  thorough  revision  which  the  work  has  so  recently  received  in 
England,  has  rendered  unnecessary  any  elaborate  additions  in  this  country,  but  the  American 
Editor,  Professor  Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to 
be  requisite  for  the  student.  Every  care  has  been  taken  with  the  typographical  execution,  and 
the  work  is  presented,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the 
text-book  for  the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial 
care  is  directed  to  show  the  applications  of  physiology  in  the  various  practical  branches  of 
medical  science.     Notwithstanding  its  very  great  enlargement,  the  price  has  not  been  in- 
creased, rendering  this  one  of  the  cheapest  works  now  before  the  profession. 


We  have  been  agreeably  surprised  to  find  the  vol- 
ume BO  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  tho  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sense  of  the  word,  is  the  production  of  a  philoso- 
pher as  well  as  a  physiologist,  brought  it  up  as  fully 
aa  could  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  io  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Duease,  April,  1877. 

"Good  wine  needs  no  bush"  says  the  proverb,  and 
an  old  and  faithful  servant  like  the  "  big"  Carpenter,as 
carefully  brought  down  as  this  edition  has  been  by  Mr. 
Henry  Power,  needs  little  or  no  commendation  by  us. 
Such  enormous  advances  have  recently  been  made  in 
our  physiological  knowledge,  that  what  was  perfectly 
new  a  year  or  two  ago,  looks  now  as  if  it  had  been  a 
received  and  established  fact  for  years.  In  this  ency- 
clopaedic way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 


subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gazette,  Feb.  17, 1877. 

Thus  fully  are  treated  the  structure  and  functions  ol 
all  the  important  organs  of  the  body,  while  there  are 
chapters  on  sleep  and  somnambulism ;  chapterson  eth 
nology,  a  full  section  on  generation,  and  abundant  re- 
ferences to  the  curiosities  of  physiology,  as  the  evolu 
tion  of  light,  heat,  electricity,  etc.    In  short,  this  new 
edition  of  Carpenter  is,  as  we  have  said  at  the  start, 
a  very  encyclopedia  of  modern  physiology. — The  Clin- 
ic,  Feb.  24, 1877. 

The  merits  of  "  Carpenter's  Physiology"  are  sow  idely 
known  and  appreciated  that  we  need  only  allude  briefly 
to  the  fact  that  in  thelatestedition  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio 
logical  investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestowed 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — JV.  Y.  Med.  Journal,  Jan.  1877. 

A  more  thorough  work  on  physiology  could  not  be 
found.  In  this  all  the  facts  discovered  by  the  late  re- 
searches are  noticed,  and  neither  student  nor  practi- 
tioner should  be  without  this  exhaustive  treatise  on  afc 
important  elementary  branch  of  medicine. — Atlanta 
Med.  and  Surg.  Journal,  Dec.  1876. 


ITIRKES  (  WILLIAM  SENHOUSE),  M.D. 

A  MANUAL  OF  PHYSIOLOGY.    Edited  by  W.  MORRANT  BAKER, 

M.D.,  F.R.C.S.  A  new  American  from  the  eighth  and  improved  London  edition.  With 
about  two  hundred  and  fifty  illustrations.  In  one  large  and  handsome  royal  12mo.  vol- 
ume. Cloth,  $3  25  ;  leather,  $3  75.  (Lately  Issued.) 

Kirkes'  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenienttext-book, 
presenting  within  a  narrow  compass  all  that  is  important  for  the  student.  The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep 
it  thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the 
eighth  edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  re- 
garded as  the  latest  accessible  exposition  of  the  subject. 

On  the  whole,  there  Is  very  little  in  the  book    the   hands  of  students. — Boston  Med.  and  Surg, 


which  either  the  student  or  practitioner  will  not  find 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  changing  science;  and  we 
have  no  hesitation  in  expressing  our  opinion  that 
this  eighth  edition  la  one  of  the  best  handbooks  on 
physiology  which  we  have  in  our  language.— N.  Y. 
Med  Record,  April  16,  1873. 

The  book  is  admirably  adapted  to  be  placed  in 


Journ.,  April  10,  1873. 

In  its  enlarged  form  it  is,  in  onr  opinion,  still  the 
best  book  on  physiology,  most  useful  to  thestudent. 
—Phila.  Med.  Timeg,  Aug.  30,  1873. 

This  is  undoubtedly  the  best  work  for  students  of 
physiology  extant.— Cincinnati  Med.  News,  Sept. 
1S73. 


HENRY  C.  LEA'S  PUBLICATIONS — (Physiology}. 


nALTON  (J.  C.),  M.D., 

-*-^  Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  Ac. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  and  sixteen  illustrations  on  wood.  In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.  Cloth,  $5  50  ;  leather,  $6  50.  (Just  Issued.} 

During  the  past  few  years  several  new  workson  phy- 1      This  popular  text-book  on  physiology  comes  to  us  in 
Biology,  and  new  editions  of  old  works,  have  appeared,  |  its  sixth  edition  with  theaddition  of  about  fifty  percent. 


competing  for  the  favor  of  the  medical  student,  but 
none  will  rival  this  new  edition  of  Dalton.  As  now  en- 
larged, it  will  be  found  also  to  be.  in  general,  a  satisfac- 
tory work  of  reference  for  the  practitioner. — Chicago 
Med.  Journ.  and  Examiner,  Jan.  1876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  regarding  physiological  questions  with  a 
fairness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vigor  to  the  entire  book.  But  his  discussions 
have  been  go  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  al  best 
exist  in  the  minds  of  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errors  while  making  them  a  study. — The  Medical 
Record,  Feb.  19, 1876. 

The  revision  of  this  great  work  has.brought  it  forward 
with  the  physiological  advances  of  the  day.  and  renders 
it,  as  it  has  ever  been,  the  finest  work  for  students  ex- 
tant.— Nashville  Journ.  of  Med.  and  Sura.,  Jan.  1876. 

For  clearness  and  perspicuity,  Dal  ton's  Physiology 
commended  itself  to  the  student  years  ago.  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiology  has,  however,  made  many  ad- 
vances since  then— and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreast  of  the  times.  The  new  chemical 
notation  and  nomenclature  have  also  been  introduced 
in^to  the  present  edition.  Notwithstanding  the  multi- 
plicity of  text-books  on  physiology, this  will  lose  none 
of  its  old  time  popularity.  The  mechanical  execution 
of  the  work  is  all  that  could  be  desired. — Peninsular 
Journal  of  Medicine,  Dec.  1875. 


of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  systt  m,  where  the 
principal  advances  have  been  realized.  AVith  so  tho- 
rough revision  and  additions,  that  keep  the  work  well 
up  to  the  times,  its  continued  popularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. —  St.  Lnuis  Med.  and  Surg.  Journ  ,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
admirable  text  book,  than  which  thereare  noneofequt;! 
brevity  more  valuable.  It  iscordially  recommended  by 
the  Professor  of  Physiology  in  theUniversity  of  Louisi- 
ana, as  by  all  competent  teachers  in  theUnited  States, 
and  wherever  the  English  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  316 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  much  enlarged,  although  its  bulk  does 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  it  doss  so  more  fully  and  satisfactorily 
thananypreviousedition.Takeitaitogf-therit  remains 
in  our  humble  opinion,  thebest  text  book  on  physiology 
in  any  land  or  language.—  The  Clinic.  Nov.  6,  1875. 

As  a  whole,  we  cordially  recommend  the  work  as  a 
text-book  for  the  student,  and  as  one  of  the  best. — 
The  Journal  of  Nervous  and  Mental  Disease,  Jan.  1876. 

Still  holds  its  position  as  a  masterpiece  of  lucid  writ- 
ins,  and  is,  we  believe,  on  the  whole,  the  best  book  to 
place  in  the  hands  of  the  student.—  London  Students' 
Journal. 


DUNGLISON  (ROBLEY),  M.D., 

Professor  of  Institutes  of  Medicine,  in  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOGY.   Eighth  edition.     Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.   In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  cloth,  $7  00. 

A R TSHORNE  ( H ENR Y),  M.D., 

Professor  of  Hygiene,  etc  ,  in  the.  Univ.  ofPfnna 

HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     Second  Edi- 
tion, revised.    In  one  royal  12ino.  vol.,  with  220  wood -cuts  :  cloth,  $1  75.     (Just  Issued.) 


H 


TEHMANN  (C.  #.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  GEORGE  E.  DAY,  M.D.,  F.R.S.,  <fcc.,  edited  by  R.  E.  ROGERS,  M.D.,  Professor  of 
Chemistry  in  the  Medical  Department  of  theUniversity  of  Pennsylvania,  with  illustratioi  s 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  plates  Con?, 
plete  in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  two 
hundred  illustrations,  cloth,  $6  00. 


TDF  THE  SAME  AUTHOR. 

MANUAL  OF  CHEMICAL  PHYSIOLOGY.    Translated  from  the 

German,  with  Notes  and  Additions,  by  J  CHESTON  MORRIS,  M.D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  SAMUEL  JACKSON,  M.D.,  of  the  University  of  Penn- 
sylvania. With  illustrations  on  wood.  In  one  very  handsome  octavo  volume  of  336 
pages.  Cloth,  $2  25. 

J^EMSEN(IRA),  M.D.,  Ph.D^~ 

Professor  nfahfmistri/  in  the  John*  Hopkin*  University,  Baltimore. 

PRINCIPLES  OF  THEORETICAL  CHKMTSTRY,  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.  In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.  (Just  Issued.) 


R  AND  FITT1G 
OUTLINES  OF  ORGANIC  CHEMISTRY.    Translated  with  Ad- 

ditions from  the  Eighth  German  Ed.     By  IRA.  REMSEN,  M.D.,  Ph.D.,  Prof,  of  Chem. 
and  Physics  in  Williams  College,  Mass.  In  one  volume,  royal  12mo.of  550  pp.  ,  cloth,  $3. 


10 


HENRY  C.  LEA'S  PUBLICATIONS — (Ghemiatry^. 


(GEORGE),  Ph.D. 
A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  Revised  and  corrected  by  UKNBV  WATTS,  B.A.,  F  R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plate,  and  one  hundred  and  seventy -seven  illus- 
trations. A  new  American,  from  tbi  twelfth  ntid  enlarged  London  edition.  Edited  by 
ROBERT  BRIDGES,  M.D.  In  one  large  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.  (Just  Ready.) 

Two  careful  revisions  by  Mr.  Watts,  since  the  appearance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.  In 
reprinting  it,  by  the  use  of  a  small  and  exceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.  The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an- 
nounced since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimnl  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pages,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  presents, 
in  a  remarkably  convenient  and  satisfactory  man- 
ntr,  the  principles  and  leading  facts  of  the  chemistry 
of  to-day.  Concerning  the  manner  in  which  the 
various  subjects  are  treated,  much  deserves  to  be 
said,  and  mostly,  too,  in  praiee  of  the  book.  A  re- 
view of  such  a  work  af  Fowneg's  Chemistry  within 
the  limits  of  a  book-notice  for  a  medical  weekly  is 
simply  out  of  the  question. — Cincinnati  Lancet  and 
Clinic,  Dec.  14, 1878. 

When  we  state  that,  In  our  opinion,  the  present 
edition  sustains  in  every  respect  tbe  high  reputation 
which  its  predecessors  have  acquired  and  enjoyed, 
we  express  therewith  our  fall  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Ang.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English  editors  renders 
it  s  till,  perhaps,  tbe  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
of  his  student  days.  It  has,  indeed,  reached  a  some- 


what formidable  magnitude  with  its  more  than  a 
thousand  pages,  but  with  less  thnn  this  no  fair  repre- 
sentation of  chemistry  as  it  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  section*  are  very 
lucidly  arranged  to  facilitate  study  and  reference. — 
Med.  and  Surff.  Reporter,  Aug  3,  3878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice  ;  safflce  It  to  say  that 
the  revision  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  The  book  has  always  been  a  fa- 
vorite in  this  country,  anil  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige.— Sot/ton  Jour, 
of  Chemistry,  Aug.  1878. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  years  it  has  held  the  fore- 
most place  as  a  text-book,  and  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
to  time  leave  lit  tie  chance  for  «ny  wide  a  wake  rival  to 
step  before  it. —  Canadian  Pharm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  as  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  187S. 


flLASSEN  (ALEXANDER], 

Professor  in  the  Royal  Polytechnic  School,  Aix  la-Chapelle. 

ELEMENTARY   QUANTITATIVE   ANALYSIS.     Translated  with 

notes   and  additions  by  EDGAR  F.   SMITH,   Ph.D.,  Assistant  Prof,  of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.     In  one  handsome  royal  12tno.  volume,  of  324 
pages,  with  illustrations;  cloth,  $2  00.     (Just  Ready.) 
A  small,  practical,  comprehensive,  and  intelligible 


guide  to  practical  elementary  quantitative  analysis, 
and  is  particularly  adapted  to  the  wants  of  the  be- 


ginner with  laboratory  work.  — 
NJV.  12,  1878. 


Y.  Med.  Record, 


It  is  probably  the  best  manual  of  an  elementary 


nature  extant,  insomuch  as  its  methods  are  the  best. 
It  teaches  by  examples,  commencing  with  single 
determinations,  followed  by  separations,  and  then 
advancing  to  the  analysis  of  minerals  and  such  pro- 
ducts as  are  met  with  in  applied  chemistry.  It  is 
an  indispensable  book  for  students  in  chemistry. — 
Boston  Journ.  of  Chemistry,  Oct.  1878. 


/GALLOWAY  (ROBERT),  F.C.S., 

Prof  of  Applied  Chemistry  in  the  Royal  College  of  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 
don Edition.  In  one  neat  royal  12mo.  volume,  with  illustrations  ;  cloth,  $2  75.  (Lately 
Issued.) 

We  regard  this  volume  as  a  valuable  addition  to  I  acids,  and  of  compounds  and  various  secretions  and 
the  chemical  text-books,  and  as  particularly  calcn-  |  excretions  of  animal  origin. — Am.  Jour,  of  Pharm., 
lated  to  instruct  the studeat  in  analytical  researches  I  Sept.  1872. 
of  the  inorganic  compounds,  the  important  vegetable  | 


DO  WMAN  (JOHN  E.) ,  M.D. 
INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Sixth  American,  from  the  sixth  and  revised  London  edition.  With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 
2$Y  THE  SAME  AUTHOR. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.  In  one 

neat  volume,  royal  12mo.,  pp.  351,  with  numerous  illustrations;  cloth,  $2  25. 


HENRY  C.  LEA'S  PUBLICATIONS — (Chemistry}. 


11 


A  TTFIELD  (JOHN),  Ph.D., 

•^-*-  Profexifur  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain.  Ac. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACBUTICAI  ; 

including  the  Chemistry  of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application.^  Medicine  and  Pharmacy.  Eighth  edition  revis-ed 
by  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustrations. 
Cloth,  $2  50  ;  leather,  $3  00.  (Just  Ready.) 

EXTRACT    FROM    THE    PREFACE. 

The  present,  Eighth,  edition  contains  such  alterations  and  additions  as  seemed  necessary  for 
the  demonstration  of  the  latest  developments  of  chemical  principles  and  the  latest  applications 
of  chemistry  to  Pharmacy.  The  Author  has  bestowed  assiduous  labor  on  the  revision,  and 
the  extent  of  the  information  thus  introduced  may  be  estimated  from  the  fact  that  the  Index 
contains  three  hundred  new  references  relating  to  the  additional  material.  The  work  LOW 
includes  the  wholp  oCthe  chemistry  of  the  United  States  Pharmacopoeia,  of  the  British  Pharma- 
copoeia, and  of  the  Pharmacopoeia  of  India. 

Engravirgs,  by  G.  Pearson,  Esq.,  of  most  of  the  important  pieces  of  apparatus  employed  in 
studying  chemistry  experimentally,  are  reproduced  in  this  Eighth  Edition.  The  twenty  micro- 
scopic views  are  after  drawings  by  TufFen  West,  Esq. 


DLOXAM  (C.  L.), 

•^-^  Profesaor  of  Ohemixtry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Lor- 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00;  leather,  $5  00.     (Lately  Issued.) 

We  have  in  this  work  a  complete  and  most  excel- 1  of  that  science  as  it  now  stands.  We  have  spoken 
lent  text-book  for  the  u.-e  of  schools,  and  can  heart- 1  of  the  work  as  admirably  adapted  to  the  wants  of 


ily  recommend  it  as  such. — Boston  Med.  and  Surg. 
Journ.,  May  28,  1S74. 

The  above  is  the  title  of  a  work  which  we  can  most 
conscientiously  recommend  to  students  of  chemis- 
try. It  is  as  easy  as  a  work  on  chemistry  could  be 
made,  at  the  same  lime  that  it  presents  a  full  account 


students  ;  it  is  quite  as  well  suited  to  the  require- 
ments of  practitioners  who  wish  to  review  their 
chemistry,  or  have  occasion  to  refresh  their  memo- 
ries on  any  point  relating  to  it.  In  a  word,  it  is  a 
book  to  be  read  by  all  who  wish  to  know  what  is 
thechemistry  of  the  present  day. — American  Prac- 
titioner, Nov.  1873. 


C 


fLO  WES  (FRANK),  D.Sc..  London. 

Senior  Science- Waster  at  the  High  School,  Jfewcastle-undr.r  Lyme,  etc. 


AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Laboratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth,  $2  50.  (Now  Ready.) 

It  is  short,  concise,  and  eminently  practical.  We  [  are  so  pimple,  and  yet  concise,  as  to  be  interesting 
therefore  heartily  commend  it  to  studen's,  ami  e=<pe-  j  and  intellig:ble.  The  work  is  unincumbered  with 
ciaily  10  those  who  are  obliged  to  dispense  with  a  j  theoretical  deductions,  dealing  wholly  with  the 
master.  Of  coarse  a  teacher  is  in  every  way  desi-  practical  matter,  which  it  is  theaimofthis  cornpre- 
rablp,  but  a  good  degree  of  technical  skill  and  prac-  |  hensive  text-book  to  impart.  The  accuracy  of  the 


tical  knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St  Louis  Clin.  Record,  Oct. 
1877. 

The  work  is  so  wriUen  and  arranged  that  it  can  be 
comprehended  by  the  student  without  a  teacher,  a ud 
the  descriptions  and  directions  for  the  various  work 


analytical  methods  are  vouched  fur  frvm  the  fact 
that  they  have  all  been  worked  throngh  by  tbe 
author  and  the  members  of  his  cias*.  from  the 
printed  text.  We  can  heartily  recommend  the  woi  k 
to  the  student  of  chemistry  as  being  a  reliable  a>"d 
cornnrfihensive  ou.Q.—Druggitts''  Advertiser,  Oct. 
15.  1877. 


KNA.PP'8  TECHNOLOGY;  orChemistry Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  WALTER  R.  JOHNSON.  In  two 


very  handsome  octavo  volumes,  with  SOOwoid 
engravings,  cloth,  $6  00. 


ffARQUHARSON  (ROBERT),  M.D., 

Lecturer  on  Materia  Mf.dica  at  St.  Mary"1 8  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.     Ed- 

ited,  with  Additions,  embracing  the  U.  S.  Pharmacopoeia.  By  FRANK  WOODBCKIT,  M.D. 
In  one  neat  royal  12mo.  volume  of  over  400  pages  :  cloth,  $2.     (Just  Issued.) 

Many  persons  who   learned   therapeutics   before     it  straight  across  the  page,  we  at  once  perceive  the 

relations  of  the  one  to  the  other.   On  this  account,  the 


the  physiological  action  of  remedies  was  taught  to 
students  find  it  difficult  to  discover  the  bearing  of 
physioloeical  action  on  therapeutic  employment 


work  is  likely  to  be  useful,  not  only  to  students  pre- 
paring for  their  examinations,  but  to  those  medical 


from  ordinary  text-books.   Dr.  Farquharson  has  most 

ingeniously  shown  it  by  printing  the  two  in  parallel 

columns  and  corresponding  paragraphs,  so  that,  by 

running  the  eye  down  the  left-hand  side  of  a  page  we 

got  the  physiological  actions  of  a  drug,  and  on  the  |  London  Practitioner,  January,  1878. 

right-hand  the  therapeutical  uses,  while,  by  running  I 


men,  also,  who  are  well  acquainted  with  larger 
books  on  the  same  subject,  but  experience  the  diffi- 
culty, already  mentioned,  of  seeing  the  relations 
between  the  actions  and  use  of  remedies.  —  The 


12      HENRY  C.  LEA'S  PUBLICATIONS — (Mat.  Med.  and  Therapeutics). 


PARRISH  (EDWARD), 

Late  ProfessorofMaterirt  Medico,  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.     Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  an  I 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  THOMAS  S.  WIEGAND.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations  ;  cloth,  $5  50  ;  leather,  $6  50. 
(Lately  Issued.) 

Of  T)r.  Parrish's  great  work  on  pharmacy  It  only  |  the  work,  not  only  to  pharmacists,  but  also  to  the 
remains  to  be  said  that  the  editor  has  accomplished  '  multitude  of  medical  practitioners  who  are  obliged 
his  work  so  well  as  to  maintain,  in  this  fourth  edi- 1  to  compound  their  own  medicines.  It  will  ever  hold 
tion,  the  high  standard  of  excellence  which  it  bad  |  an  honored  place  on  our  own  bookshelves. — Dublin 
attainedln  previous  editions,  under  theeditorship  of  Mf.d.  Press  and  Circular,  Aug.  12,1874. 
its  accomplished  author.  This  has  not  been  accom- 


plished without  much  labor,and  many  additions  aud 
improvements,  involving  changes  in  the  arrange- 
ment of  the  several  parts  of  the  work,  and  the  addi- 
tion of  much  new  matter.  With  the  modifications 


We  expressed  our  opinion  of  a  former  edition  in 
terms  of  unqualified  pvaise,  and  we  are  in  no  rnood 
to  detract  from  that  opinion  in  reference  to  the  pre- 
sent edition,  the  preparation  of  which  has  fallen  into 
competent  hands.  It  is  a  book  with  which  no  pharma- 


endium  of  the  science  and  art  indispensable  to  the1  cl8,1  can  dispense,  and  from  which  no  physician  can 
harmacist,  and  of  the  utmost  value  to  every  i  fal1  l»  denre  Inuch  information  of  value  to  him  in 
ractilioner  of  medicine  desirous  of  familiarizing  Practice.— Pacific  Med  and  Surg.  Journ.,  June,  74. 


Perhaps  one,  if  not  the  most  important  book  npon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 


thus  effected  it  constitutes,  as  now  presented,  a  com  - 
pe 
pha 

practitioner  or  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the 
articles  which  he  prescribes  for  his  patients. — Chi- 
cago Med.  Journ.,  July,  1874. 

The  work  is  eminently  practical,  andhastherarej  "Parrish's  Pharmacy"  is  a  well-known  work  on  this 
merit  of  being  readable  and  interesting,  while  it  pre-  ;sideofthe  water,  and  the  fact  shows  us  that  a  really 
serves  astrictly  scientificcharacter.  The  whole  work  useful  work  neverbecomes  merely  local  in  its  fame, 
reflects  the  greatest  credit  on  author,  edi  tor.  and  pub-  j  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
lisher.  I  twill  convey  so  me  idea  of  the  liberality  which  [  posthumous  edition  of  "  Parrish"  has  been  saved  to 
has  been  bestowed  upon  its  production  when  we  men-1  the  public  with  all  the  mature  experience  of  its  an- 
tion  that  there  are  no  less  than  280 carefully  executed  |  thor.  and  perhaps  none  the  worse  for  a  dash  of  new 
illustrations.  In  conclusion,  we  heartily  recommend  '  blood. — Lond.  Pharm.  Journal,  Oct.  17,  1874. 


J3TILLE  (ALFRED),  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 

Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols.  of  about  2000 

pages.     Cloth,  $10;  leather,  $12.     (Lately  Issued.) 

of  the  present  edition,  a  whole  cyclopsedia  of  thera- 
peutics.— Chicago  Medical  Journal,  Feb.  1875. 

The  rapid  exhaustion  of  three  editions  and  the  uni- 
versal favor  with  which  the  work  has  been  received 
by  the  medical  profession,  are  sufficient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  us 
fnlly  sustains  this  verdict,  a  s  the  work  ha  sheen  care- 
fully revised  and  in  some  portions  rewritten,  bring- 
ing it  up  to  the  present  time  by  the  admission  of 
chloral  and  croton-chloral.  nitrite  of  amyl,  bichlo- 
ride of  methylene,  methylic  ether,  lithium  com- 
pounds, gelseminnm,  and  other  remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  1875. 

We  can  hardly  admit  that  it  has  a  rival  in  the 
multitude  of  its  citations  and  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  iu  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  state  of  knowledge  in 
pharmacodynamics,  but  as  by  far  the  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston  Med.  and.  Surg.  Journal,  Nov.f>, 
1874. 


It  is  unnecessary  to  do  much  more  than  to  an- 
nounce the  appearance  of  the  fourth  edition  of  this 
well  known  and  excellent  work.— Brit,  and  For. 
Med.-Chir.  Review,  Oct  1875. 

For  all  who  desire  a  complete  work  on  therapeutics 
and  materia  medica  for  reference,  in  casesiuvolving 
medico-legal  questions,  as  well  as  for  information 
concerning  remedial  agents,  Dr.  StilltVs  is  "par  ex-  I 
cellence"  the  work.  The  work  being  out  of  print,  by 
the  exhaustion  of  former  editions,  the  an  thor  has  laid 
the  profession  under  renewed  obligations,  by  the 
careful  revision,  important  additions,  and  timely  re 
issuing  a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publisher. — 
St.  Louis  Med.  and  Surg.  Journal,  Dec  1874. 

From  the  publication  of  the  first  edition  "Still^'s 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacuum 
which  could  he  filled  by  no  other  work  in  the  lan- 
guage, and  its  presence  supplies,  in  the  two  volumes 


QRIFFITH  (ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 

ing  and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  by  JOHN  M. 
MAISCH,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  aboutSOOpp.,  cl.,  $450;  leather,  $5  50.  (Lately  Issued.) 

A  more  complete  formulary  than  it  is  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  less  essential  to  the  practitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—  The  American  Practitioner,  Louisville,  July,  '74. 


To  the  druggist  a  good  formulary  is  simply  indis- 


.  - 

cian, and  a  work  which  shall  teach  him  the  means 


HENRY  C.  LEA'S  PUBLICATIONS — (Mat.  Med.  and  Therapeutics).       13 
BTILLE  (ALFRED),  M.D,  LL.D.,  and  /IfAlSCH  (JOHN  M.).  Ph.D.. 

O         Pro/,  of  Theory  find  Practice  of  Medicine  *L'-*-        Pr,f.  of  Mot.  MeA.  and  Hot  in   Phil  a. 

and  of  Clinical  Med.  in  Univ.  of  Pa.  dull.  Pharmacy.  S*cy.  to  the  American 

Pharmaceutical  Association. 

THE   NATIONAL  DISPENSATORY  :  Containing  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in 
the  Pharmacopoeias  of  the  United  Stntes  and  Great  Britain.  In  one  very  handsome 
octavo  volume  of  1628  pages,  with  over  200  illustrations.  Extra  cloth,  $6  75  ;  leather, 
raised  bands,  $7  50.  (Now  Ready.) 

EXTRACT  FROM  THE  PREFACE. 

"  In  the  rapid  progress  of  modern  research,  few  subjects  have  of  late  years  received  greater  acces- 
sions of  facts  than  the  group  of  sciences  connected  with  ruateria  merlica  and  therapeutics.  The 
new  resources  thus  placed  at  the  command  of  the  pharmaceutist  and  physician  have  seemed  to  the 
authors  to  justify  an  attempt  to  make,  from  the  advanced  stand-point  of  the  present  dayj  a  concise 
but  complete  statement  of  all  that  is  of  practical  importance  to  both  professions — a  digest  in  which 
that  which  is  old  and  that  which  is  new  shall  be  so  brought  together  as  to  give  to  the  reader,  within 
the  most  moderate  practicable  compass,  all  the  details  in  pharmacology,  pharmacy,  and  thera- 
peutics, which  he  is  likely  to  need  in  his  daily  avocations.  In  the  almost  infinite  accumulation  of 
material,  this  has  required  a  careful  and  conscientious  sifting  to  discard  that  which  is  obsolete, 
untrustworthy,  or  comparatively  trivial,  without  impairing  the  practical  completeness  of  the 
work.  Thnt  they  have  wholly  accomplished  their  object  the  authors  do  not  venture  to  claim  ;  but 
they  can  say  that  years  of  constant  labor  have  been  devoted  to  the  task  of  producing  a  work  to 
which  the  inquirer  may  refer  with  the  certainty  of  finding  everything  which  experience  has  stored 
up  as  worthy  of  confidence  in  the  subjects  embraced  within  its  scope." 
From  AUSTIN  FLINT,  M. D.,  Prof,  of  Principles  and  |  the  respect  and  attention  due  to  authority.  The 


Practice  of  Med.  in  Bellevue  Hosp.  Med.  Coll., 

N.  Y. 

The  Dispensatory  fills  a  vacuum  in  medical  lite- 
rature which  has  long  existed.  Of  its  large  and 
long  circulation  there  can  be  no  doubt. 

From  ROBERT  T.  EDES,  Prof,  of  Materia  Medica  in 
Med.  Dept  Harvard  Univ. 

It  seems  worthy  of  the  high  reputation  of  the  au- 
thors, and  likely  to  fulfil  the  expectations  with 
which  we  have  anticipated  its  coming.  The  accu- 
racy and  value  of  its  statements  are  of  course  as- 
sured by  the  names  of  the  authors,  and  I  am  very 
favorably  impressed  with  the  method  of  arrange- 
ment as  likely  to  facilitate  reference,  a  point  of 
great  importance  in  a  work  of  this  class.  I  am  par- 
ticularly pleased  with  the  brief  and  forcible  but  yet 
careful  and  judicious  «tat<  ments  of  the  therapeutic 
value  (and,  what  is  quite  as  important, want  of  value) 
of  the  various  drugs  treated  of. 

This  is  a  most  magnificent  work,  with  its  over  six- 
teen hundred  closely  printed  pages  and  two  hundred 
illustrations.  As  should  be  in  a  Dispensatory,  the 
alphabetical  order  of  arrangement  has  been  adopted 
throughout.  But  it  would  require  several  pages  of 
the  Medical  News  for  us  to  give  even  briefly  a  de- 
scription of  the  work.  Prof.  Stille's  work  on  Matetia 
Medica  and  Therapeutics  has  ever  since  its  publica- 
tion been  a  standard  work  on  those  subjects,  and 
this  fact  alone  is  certainly  a  guarantee  of  his  quali- 
fications for  the  important  work  of  producing  a  Dis- 
pensatory; and  as  regards  Professor  Maisch,  his 
high  standing  as  a  chemist  and  pharmaceutist  is 
well  known.  We  would  probably  make  an  impor- 
tant omission  in  our  brief  notice  of  the  work,  if  we 
failed  to  draw  attention  to  a  feature  quite  novel  in  a 
Dispensatory,  namely,  the  possession  of  a  Thera- 
peutical Index.  By  reference  to  it  the  physician 
can  see  at  a  glance  the  remedies  usually  employed 
in  any  disease.  The  Index  of  Materia  Medica  covers 
fifty-five  triple  columned  pages,  and  contains  about 
10,400  references.  The  Therapeutical  Index  occupies 
thirty-three  double  columned  pages,  and  contains 
about  37oO  references.  —  Cincinnati  Med.  News, 
March,  1879. 

The  present  Dispensatory  is  arranged  in  alpha- 
betical order  from  the  commencement,  the  recent 
tdvances  in  chemistry  are  mentioned,  and  an  effort 
made  to  include  the  late  novelties  in  the  review  of 
the  resources  of  the  physician.  This  is  carried  out 
with  that  sound  conservative  judgment  which  cha- 
racterizes all  Prof.  Stille's  work.  The  chemical 
and  pharmaceutical  sections  have,  we  may  suppose, 
received  the  especial  care  of  Prof.  Maisch  ;  and  as 
he  is  fnfile,  princ°p#  in  that  branch,  nothing  can  be 
said  of  them  except  in  praise. — Med.  and  Surg.  Re- 
porter April  5,  1879. 

It  bas  been  prepared  by  two  gentlemen  whose 
learning  fully  qualified  them  for  the  difficult  task, 
and  whose  eminence  entitles  them  to  be  heard  with 


'raison  d'etre"  of  the  book  is  modestly  stated  in 
the  preface,  and  now  that  it  has  been  published  and 
opens  to  us  its  vast  stores  of  information,  we  may 
add  that  it  was  almost  a  necessity  ;  and  this  we  say 
without  meaning  to  impugn  the  great  excellence  of 
the  works  of  similar  character  which  have  preceded 
it.  All  of  the  descriptions,  whether  medical,  botan- 
ical, or  pharmaceutical,  are  clear,  in  good  English, 
and  unencumbered  with  obsolete  and  unintelligible 
terms.  Those  portions  which  have  reference  to 
therapeutics  form  a  convenient  treatise  on  that  sub- 
ject, and  are  made  the  more  valuable  and  available 
by  a  complete  therapeutical  index.  The  purely 
pharmacal  part  is  as  perfect  as  it  is  possible  to  make 
it,  and  less  could  not  have  been  expected  when  we 
consider  Prof.  Maisch's  great  qualifications  for  work 
of  that  kind.— N.  O  Med.  Journ.,  March,  1S79. 

The  therapeutic  part  is  as  rich  as  would  be  ex- 
pected of  the  author  of  the  most  comprehensive  work 
on  the  subject  in  our  language.  The  physiological 
effects  of  drugs  receive  due  attention,  and  their  in- 
fluence over  disease  is  stated  succinctly.  For  the 
task  of  winnowing  the  immense  accumulation  of 
periodical  literature,  the  experience  and  matured 
judgment  of  Prof.  Stille  were  eminently  fitted.  No 
pharmacist  or  doctor  will  repent  the  purchase  of  a 
book  which  is  at  once  a  treasury  of  facts  and  the 
digest  of  a  decision  of  a  high  court.  —Louisville  Med. 
News,  March  29,  1879. 

The  pharmaceutical  world  has  for  a  long  time 
been  ou  the  qui  vive,  in  expectation  of  the  forthcom- 
ing Dispensatory  by  Profs.  Stille  and  Maisch,  who 
have  acquired  such  a  reputation  in  their  respective 
Departments  that  nothing  but  a  satisfactory  work 
could  be  expected  ;  this  expectation  has  been  quite 
realized.  We  have  examined  the  work  with  some 
care,  and  are  very  much  pleased  that  we  can  pro- 
nounce it  to  be  reliable,  ccmprehensive,  and  Includ- 
ing the  latest  researches  available  to  its  authors. 
This  is  more  particularly  true  as  regards  the  portion 
devoted  to  pharmaceutical  subjects.  We  are  fully 
justified  in  stating  that  it  is,  taken  altogether,  one 
of  the  most  important  and  creditable  publications 
which  have  of  late  been  issued  by  the  American 
press.  It  will  be  an  indispensable  reference  book 
both  for  the  pharmacist  and  the  physician.—  New 
Remedies,  April,  1879. 

A  careful  examination  of  the  work  calls  forth  un- 
qualified praise  for  its  excellent  arrangement,  full 
yet  conclee  information,  its  careful  adherence  to  the 
best  authority  on  each  particular  topic,  as  well  as 
the  entire  elimination  of  all  unnecessary  and  obso- 
lete data  and  particulars.  The  arrangement  of  all 
topics  is  purely  alphabetical,  and  with  surprising 
fidelity  to  the  wants  both  of  the  physician  and  phar- 
maceutist. New  remedies  which  have  come  into 
recent  use  are  here  found  noticed,  with  such  facts 
as  have  been  collated  from  careful  investigation. — 
Druggists'  Circular  and  Chemical  Gazette.  Mareb, 
1S79. 


14 


HENRY  C.  LEA'S  PUBLICATIONS—  (Pathology,  <&c.). 


HO R NIL  (V.},  AND 

Prof,  in  the  Faculty  of  STe.d  ,  Paris. 


T>ANVIER  (/,.), 

Prof,  in  the  College  of  Prance. 


MANUAL  OP  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  nnd  Additions,  by  E.  0.  SHAKESPEARE,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Philada.  Hospital,  Lecturer  on  Refaction  and  Operative  Ophthalmic  Surgery  in  Univ. 
of  Penna.  In  one  very  handsome  octavo  volume  of  about  600  pages,  with  over  300  illus- 
trations. (Preparing.) 

So  much  has  been  done  of  late  years  in  the  elucidation  of  pathology  by  means  of  the  micro- 
scope, and  this  subject  now  occupies  so  prominent  a  position  as  one  of  the  most  important  branches 
of  medical  science,  that  the  American  profession  cannot  fail  to  welcome  a  translation  of  the  pre- 
sent work,  which,  through  its  own  merits  and  through  the  well-known  reputation  of  its  distin- 
guished authors,  is  regarded  in  Europe  as  the  standard  text-book  and  work  of  reference  in  its 
department.  Such  investigations  and  discoveries  as  have  been  made  since  its  appearance  will  be 
introduced  by  the  translator,  nnd  the  work  is  confidently  expected  to  assume  in  this  country  the 
same  position  which  has  been  so  universally  accorded  to  it  abroad. 


EN WICK  (SAMUEL),  M.D., 

Astittant  Phyaioian  to  the  London  Hotpitftl. 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.     From  the 

Third  Revised  and  Enlarged  English  Edition.     With  eighty-four  illustrations  on  wood. 
In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.     (Just  Issued.) 


Of  the  many  guide-books  on  medical  diagnosis, 
claimed  to  be  written  for  the  special  instruction  of 
students,  this  ig  the  best.  The  author  is  evidently  a 
well-read  and  accomplished  physician. and  he  knows 
how  to  teach  practical  medicine.  The  charm  of  sim- 
plicity is  not  the  least  interest!  ng  feat  lire  in  the  man- 
ner in  which  Dr.  Fen  wick  conveys  instruction.  There 


are  few  books  of  this  size  on  practical  medicine  that 
contain  so  much  and  convey  it  eo  we)  las  the  volume 
before  us.  It  is  a  book  we  can  sincerely  recommend 
to  the  student  (•>!  direct  instruction,  and  to  th (^prac- 
titioner as  a  ready  and  useful  aid  to  hi*  memory. — 
Am.  Journ.  of  Syphilography,  Jan.  1874. 


G 


RE  EN  (T.  HENRY],  M.D., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-dross  Hospital  Medical  School,  ftc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American,  from 

the  Fourth  and  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo 
volume  of  332  pages,  with  132  illustrations;  cloth,  $2  25.     (Just  Ready.) 


This  is  unquestionably  one  of  the  bes!  manuals  on 
the  subject  of  pathology  and  morbid  anatomy  that 
can  be  placed  in  the  student's  hands,  and  we  are 
glad  to  see  it  kept  up  to  the  times  by  new  editious. 
Each  edition  is  carefully  revised  by  the  author,  with 
the  view  of  making  it  include  the  most  recent  ad- 
vances in  pathology,  and  of  omitting  whatever  may 
have  become  obsolete. — N.  Y.  Med.  Jour.,  Feb.  1879. 

The  treatise  of  Dr.  Green  is  compact,  clearly  ex- 


ciently  numerous,  and  usual  y  well  made.  In  the 
present  edition,  such  new  matter  has  been  added  as 
was  necessary  to  embrace  the  later  results  iu  patho- 
logical research.  No  doubt  it  will  continue  to  enjoy 
the  favor  it  has  received  at  the  hands  of  the  proles- 
sion. — jyed  and  Surg.  Reporter,  Feb.  1,  1879. 

For  practical,  ordinary  daily  u«e,  this  is  undoubt- 
edly the  best  treatise  that  is  offered  to  btudei.ts  of 
pathology  and  morbid  anatomy. — Cincinnati  Lan- 


pressf  d,  up  to  the  limes,  and  popular  as  a  text-book,  |  cat  and  Clinic,  Feb.  8,  1879. 
both  in  England  and  America.    The  cuts  are  suffi- 


D 


AVIS  (NATHAN  S.), 

Prof,  of  Principles  and  Practice  of  Medicine,  etc.,  in  Chicago  Med.  College. 

CLINICAL  LECTURES  ON  VARIOUS  IMPORTANT  DISEASES ; 

being  acollection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  FRANK  H.  DAVIS,  M.D.  Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.  Cloth,  $1  75.  (Lately  Issued.) 


Vf  H  AT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTER 
DEATH  IN  MEDICAL  CASKS.  From  the  second  Lon- 
don edition.  1  vol  royal  12mo.,  cloth.  $1  00. 

CHRISTISON'8  DISPENSATORY.  With  copious  ad- 
ditions, and  213  large  wood-engravings.  By  R. 
EuLEsFi  KI.H  GRIFFITH,  M.D.  One  vol.  8vo.,  pp.  il  00. 
oloth.  $400. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  OF 
ALCOHOLIC  LIQUORS  IN  HEALTH  AND  DISEASE.  Ne* 
edition,  with  a  Preface  by  D.  F.  CONDIE.  M.D.,  and 
explanations  of  scientific  word?.  In  oneneatl2mr. 
volume,  pp.  178,  cloth.  60  cents. 

OLUGE'8  ATLAS  OF  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  JOSBPH 
LEIDT,  M.  D.  In  one  volume,  very  large  imperial 
quarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  $400. 

LA  ROCHE  ON  YELLOW  FEVER, considered  in  its 
Historical,  Pathological,  Etiological,  and  Thera 
peutical  Relations.  In  two  large  and  handsome 
octavo  volumes  of  nearly  1300  pp.,  cloth.  $7  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIOIU.  1  vol.  8vo.,  pp.  500,  cloth.  $3  60. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OP 
MEDICINE.  With  Additions  by  D.  F.  CONDIE, 
M.  D.  1  vol.  8vo.,  pp.  600,  cloth.  $2  50. 

TODD'SCLINICALLECTURESoNCERTAIN  ACUTE 
DISEASES.  In  one  neat  octavo  volume,  of  320  pp., 
•loth.  *2  50. 

STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  MEDICINE.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  haudsome  12mo. 
volume,  cloth,  $1  23.  (Lately  Issued.) 

STOKES'  LECTURES  ON  FEVER.  Edited  by  JOHN 
WILLIAM  MOORE,  M.  D.,  Assistant  Physician  to  the 
Cork  Street  Fever  Hospital.  In  one  neat  Svo. 
volume,  cloth,  $2  00.  (Just  Issued) 

THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE: 
comprising  Treatises  on  the  Nature  and  Treatment 
of  Diseases,  Materia  Medica  and  Therapeutics,  Dis- 
eases of  Women  and  Children.  Medical  Jurispru- 
dence, etc.  etc.  By  DITNGLISON,  FORBKS,  TWKEDIE, 
and  CONOLLT.  In  four  large  super-royal  octavo 
volumes,  of  3254  double-columned  page*,  strongly 
and  handsomely  bound  in  leather,  $15;  cloth,  $11. 


15 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine). 
U1LINT  (A  UST1N),  M.D., 

•*•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Belle-one  3fed  College,  N.  Y. 

A   TREATISE    ON   THE    PRINCIPLES  AND    PRACTICE    OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  ahout 
1100  pp.;  cloth,  $6  00  ;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00.  (Lately 
Issued. ) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condi- 
tion of  medical  science.     At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one 
of  the  cheapest  volumes  now  before  the  profession. 
This  excellent  treatise  on  medicine  has  acquired    in  which  one  of  its  editions  is  not  to  be  found.  Tie 


foritselfin  the  United  States  a  reputation  similar  to 
thatenjoyed  in  England  by  the  admirable  lectures 
of  Sir  Thomas  Watson.  It  may  not  possess  the  same 
charm  of  style,  but  it  has  like  solidity,  the  frnit  of 
long  and  patient  observation, and  presents  kiniired 


present  edition  has  been  enlarged  aucl  revised  lo 
briug  it  np  to  the  author's  present  level  of  experi- 
ence and  reading  His  own  clinical  studies  and  the 
latent  contributions  to  medical  literature  both  in 
this  country  and  in  Europe,  have  received  careful 


moderation  and  eclecticism.     We  have  referred  to  i  attention,  so  that  some  portions  have  been  entirely 
many  ofthe  mostimportantchapters.and  find  the  re     rewritten,  and  about  seventy  pages  of  new  matter 


vision  spoken  of  in  the  preface  isagenuineone,and 
that  the  author  has  very  fairly  brought  up  hi  smaller 
to  the  level  of  the  knowledge  of  the  present  day.  The 
work  has  this  great  recommendation,  that  it  is  in  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
English  text-books  ofmedicinehavedevelopedinto. 
—  British  and  Foreign  Sfed.-Chir.  Rev.,  Jan.  187< . 
It  is  of  course  unnecessary  tointrodnce  or  eulogize 
this  now  standard  treatise  All  the  colleges  recom 


harebeen  added.  —Ckivngn  lUfd  Jour.,  June,  1873. 

Has  never  been  surpassed  as  a  text-book  for  stu- 
dents and  a  book  of  ready  reference  for  practition- 
ers The  forcp  of  its  logic,  its  simple  and  practical 
teachings,  have  left  it  without  a  rival  in  the  field. 
N.  Y.—Med  Record,  Sept.  16,  1874. 

It  is  given  to  very  few  men  to  tread  in  the  steps  of 
Austin  Flint,  whose  single  volume  on  medicine, 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensatioo  and  of  general  grasp  of  an  enor- 


mend  it  as  a  text-book,  and  there  are  few  libraries    mously  wide  subject — Land.  Practitioner, Dec. '73. 


J^Y  THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;    a  Systematic   Treatise  on    the  Diagnosis 

and  Treatment  of  Diseases.      Designed  for  Students  and  Practitioners  of  Medicine.     In 
one  large  and  handsome  octavo  volume.     (In  Press  ) 

JRF  THE  SAME  AUTHOR. 

ESSAYS    ON    CONSERVATIVE    MKDICTNE    AND    KINDRED 

TOPICS.     In  one  very  handsome  royal  I2rao.  volume.     Cloth,  $1  38.     (Just  Iss  ted.) 


fflOODBURT  (FRANK),  M.D., 


Physician  to  the  German  jSo&pitat,  Philadelphia,  late  Physician  to  the  Out-patient  Department 
of  the  Jeff  College  Hospital,  etc. 

A    HANDBOOK   OF   THE   PRINCIPLES  AND    PRACTICE    OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.  Based  upon  Husband's  Handbook 
of  Practice.  In  one  neat  volume,  royal  12mo.  (In  Press.) 

PJARTSHORNE  (HENRY),  M.D., 

•^~*-  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  ME!  I- 

CINE.  A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  handsome  royal  12mo.  volume, 
of  about  550  pages,  cloth,  $2  63  ;  half  bound,  $2  88.  (Lately  Issued.) 


As  ahandbook,  which  clearly  sets  forth  the  ESSEN- 
TIALS Of  the  PRINCIPLES  AND  PRACTICE  OF   MEDICINK, 

we  do  not  know  of  its  equal.—  Va.  Med.  Monthly. 
As  a  brief,  condensed,  but  comprehensive  hand- 


book, it  cannot  be  improved  upon. — Chicago  Med. 
Examiner,  Nov.  15,  1874. 

Without  doubt  the  best  book  of  the  kind  published 
in  the  English  language. — St.Lov.ieMtd.and Sury. 
Journ.,  Nov.  1874. 


WATSON  (THOMAS),  M.D.,  frc. 
r  LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
tions,  by  HENRY  HARTSHORNS,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania. In  two  large  and  handsome  8vo.vols.  Cloth,  $9  00  ;  leather,  $11  00.  (Lately 
Published.) 

^It  is  a  subject  for  congratulation  and  for  thank-  ,  eate  and  important  pathological  and  practical  ques- 
fuliess  that  Sir  Thomas  Watson, during  a  period  of  1  tions,  the  results  of  his  clear  insight  and  his  calm 
comparative  leisure,  after  a  long,  laborious,  and  j  judgment  are  now  recorded  for  the  benefit  of  man- 
most  honorableprofessional  career,  while  retaining  kind,  in  language  which,  for  precision,  vigor,  and 
full  possession  of  his  high  mental  faculties,  should  classical  elegance,  has  rarely  been  equalled,  and 
have  employed  the  opportunity  to  submit  his  Lee-  ]  never  surpassed  The  revision  has  evidently  been 
tares  to  a  more  thorough  revision  than  wa  possible  i  most  carefully  done,  and  the  results  appear  in  al- 
during  the  earlier  and  busier  period  of  his  life,  i  most  every  page. — Brit.  Med.  Journ.,  Oct.  14,  1871. 
Carefully  passing  in  review  some  of  the  moeiintri-  I 


16  HEXRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine^. 

DRISTO  WE  (JOHN-  STER),  M.D  ,  F.R.C.P., 

J—J  Physician  and  Joint  Lecturer  on  Medicine.,  St.  Thfimax'x  Hnspital. 

A  MANUAL  ON  THE  PRACTICE  OF  MEDICINE.    Edited,  with 

Additions,  by  JAMES  H.  Hm  CHIJJSON,  M.D.,  Physician  to  the  Penna.  Hospital.  In  one 
handsome  octavo  volume  of  over  1100  pages  :  cloth,  $5  50;  leather,  $6  50.  (Just  Issued.) 
This  portly  volume  is  a  model  of  condensation,  i  increxsed  by  the  judijious  notes  of  the  Editor.— 
In  a  style  at  once  clear,  interesting, and  concise,  Dr.  \  Cincinnati  Clinic,  Jan  7,  1877. 
Bristowe  passes  in  review  every  conceivable  subject  j  Any  one  who  Want8  a  good  clear  condenfsed  work 
connected  wUh  the  practice  o •medicine  Those  ;  n  p,)QJpracMce .  quite  u  p  with  the  mostrecent  viewsin 
practitioners  who  purchase  few  books  will  find  this  j  pa,hology,  will  find  this  a  most  valuable  work  The 
a  mott  opportune  publication,  because  -o  many  top-  |  additions  made  by  Dr.  Hutchinson  are  appropiiate 
ics  not  usually  embraced  in  a  work  on  practice  are  ,  and  nseful.andso  well  done  that  we  wi>h  therewere 
adequate  y  handled.  The  book.s  athorougblyg.^  j  more  of  tbera._awl.  Practitioner,  Feb.  1S77. 
one,  and  its  usefulness  to  American  readers  has  been  i 

fJABERSHON  (S.  0.},  M.D. 

•*--*-  Senior  Physician  to  and  late  Lecturer  on  the  Principles  and  Practice  of  Medicine  at  Guy's 

Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intes- 
tines, and  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.  (Now  Heady.) 

This  work  has  remained  s^me  time  out  of  print,  owing  to  the  careful  and  conscientious 
revision  which  it  has  enjoyed  at  the  hands  of  the  author,  und  which  h:is  nearly  doubled  its 
size  since  the  appearance  of  the  first  edition.  Yet  there  is  no  work  accessible  to  the  profession 
to  take  its  place,  as  a  careful,  practical  guide  on  a  class  of  diseases,  which  form  so  large  and 
important  a  portion  of  the  duties  of  the  physician,  and  for  which  the  author's  position  has 
given  him  almost  unequalled  opportunities  for  observation  and  experience.  The  very  extensive 
scope  of  the  volume  will  be  seen  by  the  subjoined  condensed 

SUMMARY  OF  CONTENTS. 

Chapter  I.  Introduction.  II.  On  Diseases  of  the  Tongue  and  Mouth.  III.  On  Diseases  of 
the  Pharynx.  IV.  On  diseases  of  the  (E.sophagus.  V.  On  Organic  Diseases  of  the  Stomach. 
VI.  On  Functional  Diseases  of  the  Stomach.  VII.  On  Diseases  of  the  Duodenum  VIII. 
On  Muco-Enteritis  and  Enteritis.  IX.  On  Strumous  and  Tubercular  Disease  of  the  Alimen- 
tary Canal ;  Lardaceous  Disease.  X.  On  Diseases  of  the  Cfecum  and  Appendix  Caeci.  XI. 
On  Diarrhoea.  XII.  On  Dysentery  and  Catarrhal  Inflammation  of  the  Colon.  XIII.  On 
Typhoid  Disease  of  the  Intestine.  XIV.  On  Colic.  XV.  On  Constipation.  XVI.  On  Organic 
Obstruction,  Internal  Strangulation,  Intussusception,  and  Carcinoma  of  Intestine.  XVII. 
On  Suppuration  of  the  Abdominal  Parietes,  Perforation  of  the  Intestine  from  without,  and 
Abscess  of  the  Abdominal  Parietes  extending  into  the  Intestine;  Fecal  Abscess.  XVIII. 
On  intestinal  Worms.  XIX.  On  Peritonitis.  XX.  On  Aecites,  Dropsy.  XXI.  On  Abdomi- 
nal Tumors. 

This  valuable  treatise  on  diseases  of  the  stomach  ;  amended  by  the  author.  Several  new  chapters  have 
and  abdonen  has  been  out  of  print  for  several  years,  been  added,  bringing  the  work  fully  up  to  the  times, 
and  is  therefore  not  so  well  known  to  the  profession  and  making  it  a  volume  of  interest  to  the  practitioner 
as  it  deserves  to  be.  It  will  be  found  a  cyclopaedia  in  every  field  of  medicine  and  surgery.  Perverted 
of  information,  systematically  arranged,  on  all  dis-  j  nutrition  is  in  some  form  associated  with  all  diseases 
eases  of  the  alimentary  tract,  from  the  month  to  the  i  we  have  to  combat,  and  we  need  all  the  light  that 
rectum.  A  fair  proportion  of  each  chapter  is  devot-  |  can  be  obtained  on  a  subject  so  broad  and  general, 
ed  to  symptoms,  pathology,  and  therapeutics.  The 


present  edition  is  fuller  tnan  former  ones  in  many 
particulars,  and  has  been  thoroughly  revised  and 


Dr  Habershon's  work  is  one  that  every  practitioner 
should  read  and  study  for  himself. — N.  Y.  Mtd. 
Journ.,  April,  1879. 


mTHERGlLL  (J.  MILNER},M.D.  Edin.,  M.R.C.P.  LomL, 

J-  Asst.  Phys.  to  the  West  Land.  Hasp.  ;  Asst.  Phya.  to  the  City  of  Lond.  Ho*p. ,  etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  550  pages  :  cloth, 
$4  00.     (Now  Ready.) 


Our  friends  will  find  this  a  very  readable  book ;  and 
that  it  sheds  light  upon  every  theme  it  touches,  causing 
the  practitioner  to  feel  more  certain  of  his  diagnosis  in 
difficult  cases.  We  confidently  commend  the  work  to 
our  readers  as  one  worthy  of  careful  perusal.  It  lights 
the  way  over  obscure  and  difficult  passes  in  medical 
practice.  The  chapter  on  the  circulation  of  the  blood 
is  the  most  exhaustive  and  instructive  to  be  found.  It 
is  a  book  every  practitioner  needs,  and  would  have,  if 
he  knew  how  suggestive  and  helpful  it  would  be  to 
him. — St.  Louit  tied,  and  Surg.  Journ,  April,  1877. 

It  is  our  honest  conviction,  after  a  careful  perusal  of 
this  goodly  octavo,  that  it  represents  a  great  amount  of 
earnest  thought  and  painstaking  work,  and  is  therefore 


one  of  those  books  which  both  deserve  and  are  likely  to 
survive.  This  book,  although  written  ostensibly  for  the 
young  and  inexperienced,  may  be  very  profitably  studied 
by  those  who  have  been  practicing  their  profession 
more  or  less  empirically  for  thirty  or  forty  year*.  We 
content  ourselves  with  again  recommending  the  book 
very  cordially. — Edin.  Med.  Journ.,  Jan.  1-77. 

We  heartily  commend  his  book  tothemedical  student 
as  an  honest  and  intelligent  guide  through  the  mazes  of 
therapeutics,  and  assure  the  practitioner  who  ha.<  grown 
gray  in  the  harness  that  be  will  derive  pleasure  and  iu- 
jtruction  from  its  perusal  Valuable  suggestions  and 
material  for  thought  abound  throughout.—  Boston  Med. 
and  Surg  Journal,  Mar  8, 1877. 


TOT  THE  SAME  AUTHOR. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.    Being  the  Fothergillian  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
12mo.  of  156  pages;  cloth,  $1  00.     (Just  Ready.) 

It  will  be  found  a  highly  interesting  study  and  I  certain    drags. —  Medical  and    Surgical   Reporter, 
practical  application  of  the  antagonistic  action   of  1  Sept.  11,  1S7S. 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine}. 


17 


fllNLAYSON  (JAMES},  M.D., 

Physician  and  Lecturer  on  Olinical  3fedi"ine  in  >h*  GlaAffow  Western  Infirmary,  etc. 

CLINICAL    DIAGNOSIS;    A    Handbook    for    Students    and    Prac- 

titioners  of  Medicine.     In  one  handsome  12mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2   63.      (Just  Ready.) 

The  concurrence  of  gentlemen  specially  familiar  with  the  several  subjects  being  requisite  to 
the  satisfactory  development  of  a  plan  so  extensive,  Dr.  Finlayson  has  secured  the  co-operation 
of  Prof.  Gairdner,  who  has  contributed  the  chapter  on  the  Physiognomy  of  Disease;  Prof.  Wm. 
Stephenson  that  on  Disorders  of  the  Female  Organs;  Dr.  Alex.  Robertson  that  nn  Insanity; 
Prof.  Samson  Gemmell  those  on  the  Sphygmograph  and  Physical  Diagnosis;  and  Dr.  Joseph 
Coates  those  on  the  Fauces,  Larynx,  and  Nares,  and  on  the  method  of  performing  post-mortem 
examinations.  Other  chapters  have  enjoyed  the  advantage  of  revision  by  gentlemen  specially 
versed  in  their  several  subjects;  and  the  volume  is  presented  as  thoroughly  on  a  level  with 
the  most  advanced  condition  of  knowledge  in  a  department  which  has  made  such  rapid  strides 
of  advancement  within  the  last  few  years. 

The  book  is  an  excellent  one,  clear,  concise,  conve-  This  is  one  of  the  really  useful  books.  It  is  attrac- 
nient,  practical.  It  is  replete  with  the  very  know-  j  live  from  preface  to  the  final  page,  and  ought  to  be 
ledge  the  student  needs  when  he  quits  the  lecture-  ]  given  a  place  on  every  office  table,  because  it  contains 
room  and  the  laboratory  for  the  ward  and  sick-room,  in  a  condensed  form  all  that  is  valuable  in  semeiology 
and  does  not  lack  in  information  that  will  meet  the  i  and  diagnostics  to  be  found  in  bulkier  volumes,  and 
wants  of  experienced  and  older  men. — Phila.  Med.  j  because  in  its  arrangement  and  complete  index,  it  is 
Times,  Jan.  4,  1879.  j  unusually  convenient  for  quick  reference  in  any 

The  aim  of  the  author  is  to  teach  a  student  and  |  emergency  that  may  come  upon  the  busy  practitioner, 
practitioner  how  to  examine  a  case  so  as  to  use  "all  •.  """•"•  G-  Mea-  J°urn->  Jan.  1879. 

his  knowledge"  in  arriving  at  a  diagnosis.  All  the  !  This  is  a  most  important  work  for  students,  and 
various  symptoms  of  the  several  systems  are  grouped  :  one  that  is  destined  to  become  rapidly  popular.  It 
together  in  such  a  manner  as  to  make  their  relations  '  is  composed  of  contributions  from  various  eminent 
to  a  final  diagnosis  clear  and  easy  of  apprehension,  i  sources  bearing  upon  this  subject.  The  real  secret 
This  work  has  been  done  by  men  of  large  experience  of  successful  practice  is  the  accurate  diagnosis  of 
and  trained  observation,  who  have  been  long  recog-  j  disease.  This  manual  teaches  the  student  to  arrange 
nized  as  authorities  upon  the  subj  cis  which  they  his  investigation  in  such  system  as  to  enable  him, 
treat.  There  is  a  profusion  of  illustrations  to  illus-  with  practice,  to  acquire  this  very  desirable  faculty. 
Irate  subjects  under  discussion.  The  application  of!  The  division  of  the  subject,  as  in  this  work,  among 
electricity,  and  instruments  of  precision  in  diagnosis,  j  the  highest  authorities  living,  is  a  good  idea,  and 
is  fully  discussed.  This  book  is  all  good.  We  com-  gives  us  in  one  compact  form  a  series  of  monographs 


mend  it  to  all  students  and  practitioners  of  medicine 
as  a  work  worthy  of  a  place  in  their  libraries. — Ohio 
Med.  Recorder,  Dec.  1878. 


written   by  masters. — Nashville  Journal  of  fifed, 
and  Surg.,  Jan.  1879. 


(ALLAN  McLANE],  M.D., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.  Y., 
and  at  the  Out- Patient  n'  Department  of  the  New  York  Hospital. 

NERVOUSDISEASES;THEIR  DESCRIPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illus.;  cloth,  $3  50.     (Just  Ready.) 
This  is  unquestionably  the  best  and   most  com- 
plete text-book  of  nervous  diseases  that  has  yet  ap- 
peared, and  were  international  jealousy  in  scientific 


affairs  at  all  possible,  we  might  be  excused  for  a 
feeling  of  chagrin  that  it  should  be  of  American 
parentage.  This  work,  however,  has  been  performed 
in  New  York,  and  has  been  so  well  performed  that 
no  room  is  left  for  anything  but  commendation. 
With  great  skill,  Dr.  Hamilton  has  presented  to  his 
readers  a  succinct  and  lucid  survey  of  all  that  is 
known  of  the  pathology  of  the  nervous  system, 
viewed  in  the  light  of  the  most  recent  researches. 
From  the  preliminary  description  of  the  methods  of 
examination  and  study,  and  of  the  instruments  of 
precision  employed  in  the  investigation  of  nervous 
diseases,  up  till  the  final  collection  of  formulae,  the 
book  is  eminently  practical. — Brain,  London,  Oct. 
1878. 

The  author  tells  us  in  his  preface  that  it  has  been 
his  object  to  produce  a  concise,  practical  book,  and 
we  think  he  has  been  successful,  considering  the  ex- 
tent of  the  subject  which  he  has  undertaken.  In 
fact,  it  is  more  extensive  than  the  title  properly  or 
accurately  indicates,  embracing — besides  what  are 
usually  regarded  as  nervous  diseases — inflammatory 
affections,  both  acute  and  chronic,  hemorrhages  and 
tumors  of  the  cerebrum  and  cerebellum,  medulla 
oblongata,  spinal  cord  and  nerves,  with  thrombosis 
and  embolism  of  the  arteries,  sinuses,  and  veins. 
The  reader  may  therefore  expect  information,  more 
or  less  full  and  satisfactory,  on  almost  every  point 


connected  with  the  nervous  system.  We  have  no 
hesitation  in  saying  that  reliance  may  be  placed  on 
Dr.  Hamilton's  conscientious  performance  of  his  self- 
assigned  task,  on  his  soundness  of  judgment,  and 
freedom  from  empiricism. — Edinburgh  Med.  Journ., 
Oct.  1S78. 

From  a  very  careful  examination  of  the  whole 
work,  we  can  justly  say  that  the  author  has  not  only 
clearly  and  fully  treated  of  diagnosis  and  treatment, 
but,  unlike  most  works  of  this  class,  it  is  very  com- 
prehensive in  regard  to  etiology,  and  exposes  the 
pathology  of  nervous  diseases  i  n  the  light  of  the  very 
latest  experiments  and  discoveries.  The  drawings 
are  excellent  and  well  selected.  After  this  careful 
revision,  we  can  heartily  recommend  this  work  to 
students  and  general  practitioners  in  particular  as 
being  a  full  exposition  of  diseases  of  the  nervous  sys- 
tem, their  pathology  and  treatment,  to  date.— JV.  Y, 
Med.  Record,  Aug.  3,  1878. 

As  stated  in  the  preface,  the  author's  object  has 
been  to  write  a  concise  and  practical  book,  for 
which  there  is  certainly  a  place,  and  we  think  he 
has  succeeded  admirably  in  fulfilling  his  object. 
The  usual  plan  is  adopted  in  tlie  classification  of 
the  different  diseases,  the  book  not  being  greatly 
unlike  Hammond's  in  this  respect,  although  it  is 
very  noticeable  throughout  that  the  author's  opin- 
ions vary  widely  from  those  of  Dr  Hammond. — Am. 
Supp.  Obstet.  Journ.  Great  Britain  and  Ireland, 
July,  1878. 


n ARGOT  (j.  m.}, 

Professor  to  the  Faculty  of  Med.  Paris,  Phys.  to  La  Salpetriere,  etc. 

LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM.    Trans- 

lated  from  the  Second  Edition  by  GEORGE  SIGEBSON,  M.D.,  M.Ch.,  Lecturer  on  Biology, 
etc.,  Cath.  Univ.  of  Ireland.  With  illustrations.  (Publishing  in  the  Medical  News  and 
Library,  commencing  with  the  July  No.  1878  See  page  2  ) 


18        HENRY  C.  LEA'S  PUBLICATIONS — [Diseases  of  the  Chesf,  <tc.). 


~RKO  WN  (LENNOX),  F.R.C.S.  Ed., 

Senior  SurOf-on  to  the  Central  London  Throat  and  Ear  Il'i/tptlal,  etc., 

THE  THllOAT   AND  ITS  DISEASES.     With  one  hundred  Typical 

Illustrations  in  colors,  and  fifty  wood  engravings,  designed  and  executed  by  the  author. 
In  one  very  handsome  imperial  octavo  volume  of  3ol  pages  ;  cloth,  $5  00.   (Now  Ready.) 

are  uuusually  accurate.  In  conclusion,  we  recom- 
mend i  his  beautiful  volume  ax  a. it  acceptable  addi- 
tion to  the  library  of  those  engaged  IL  tl>e  treatment 


The  author's  rare  artistic  skill  has  been  utili/.od 
in  the  production  of  one  hnuilred  beautiful  illustra- 
tions in  colors,  the  very  best  of  the  kind  we  have 
sppo.  and  which  have  been  distributed  in  ten  plates. 
Fifty  wood  engravings,  designed  and  executed  by 
the  anther,  appear  in  the  body  of  the  work — these 


of  diseases  of  the  throat.—  If.  Y.  Med.  Record,  Mov. 


OB1LER  (CAUL),  M.D., 

Lecturer  on  Larynyasci  py  at  the  Univ.  of  Penna  ,   Chief  of  the  Throat  Dispensary  at  the 
Univ.  Hospital,  Phila  ,  etc. 

HANDBOOK  OF  DIAGNOSIS  ANT)  TREATMENT  OF  DISEASES  OF 

THE    THROAT   AND    NASAL   CAVITIES.      In  one  handsome  royal  12mo.  volume. 
With  illustrations.      (In  P rest.) 


F' 


'LINT  (AUSTIN),  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med.  College,  Jf   Y. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 

ATIC  EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS;  in  a  series  of  Clinical  Studies.  By  AUSTIN 
FLINT,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.  In  one  handsome  octavo  volume  :  $3  50.  (Lately  Issued.) 


This  book  contains  an  aualysis,  in  the  author's  lucid 
pfyle,  of  the  notes  which  he  has  made  in  several  hun- 
dred cases  in  hospital  and  private  practice.  We  com- 


mend the  book  to  the  perusal  of  all  iuti'restt'd  iu  the 
•study  oi'ti'i"  duuasu. — Huston  Med.  and  Surg.  Journal, 
Feb.  10,  1876. 


DT  THE  SAME   AUTHOR. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.    In 
one  handsome  royal  12rno.  volume:  cloth,  $1  75.     (Just  Issued.) 


B 


Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 
Dr.  Flint  chose  a  difficult  subject  for  his  researches    and  clearest  practical  treatise  on  those  subjects,  and 


and  has  shown  remarkable  powers  of  observation 
an  1  reflection,  as  well  as  great  industry,  in  his  treat- 


should  be  in  the  hands  of  all  practitioners  and  stu- 
lents.  It  is  a  credit  to  American  medical  literature. 


men  t  of  it.    His  book  musi  be  considered  the  fullest  |   —  Amer.  Jotirn.  of  the  Med.  Sciences,  July,  1860. 
T>f  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 


WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  Wiih  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
350  pages;  clotb,  $250. 

DIPHTHERIA  ;  its  Nature  and  Treatment,  with  an 
account  of  the  History  of  its  Prevalence  in  vari- 
ous Countries.  By  D.  D.  SI.ADE,  M.D.  Second  and 
revised  edition.  In  one  neatroyal  12mo.  volume, 
cloth,  $1  25. 

WALSHEONTHEDISEASESOFTHEHEARTAND 
GREAT  VESSELS.  Third  American  Edition.  In 
1  vol.  Svo.,  420  pp.,  cloth,  $3  00. 

LECTURES  ON  THE  DISEASES  <>F  THE  STOMACH. 
With  an  Introduction  on  its  Anatomy  and  Physio- 
logy. By  WILLIAM  BRINTON,  M  D.,  F.R.S  From 
the  second  and  enlarged  Londonedltion.  With  il- 
lustrations on  wood  In  one  handsome  octavo 
volume  of  aTjont.300  pages:  cloth,  $3  26. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.,  cloth, 
of  500  pages  Price,  $3  00. 

LINCOLN'S  ELECTRO-THERAPEUTICS;  a  Concise 
Manual  of  Medical  Electricity.  In  one  very  ueat 
royal  12mo.  volume,  cloth,  with  illustrations, 
$1  50. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS  Bv  C.  HANDHIELD  JONES, 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec 
ond  American  Edition.  In  one  handsome  octavo 
volume  of  348  pages,  cloth,  $3  25. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  ocatvo 
volume  of  about  500  pages  :  cloth,  $3  50. 

CHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.  Iu  one  handsjine 
octavo  volume.  Cloth,  $2  75 

CHAMBERS'S  RESTORATIVE  MEDICINE.  An  Har- 
veian  Annual  Oration.  With  Two  Sequels.  In 
one  very  handsome  vol.  small  12<no  ,  cloth,  $1  00. 

PAVY'S  TREATiSE  ON  THE  FUNCTION  OF  DI- 
GESTION ;  its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  hand- 
some volume,  small  octavo,  cloth,  $2  00. 

PAVY'S  TREATISE  ON  FOOD  AND  DIETETICS. 
Physiologically  and  Therapeutically  Considered. 
In  one  handsome  octavo  volume  of  nearly  tiOO 
pages,  cloth,  $4  75. 

SMITH  ON  CONSUMPTION;  ITS  EARLY  AND  RE- 
MSDIABLE  STAGES.  1  vol.  8vo.,  pp.  2/54  *2  V •. 

BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions. In  one!2mo.  vol.  of  304  pages,  cMh,  $2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
HUDSON,  M.D.,  M.R.I. A.,  Physician  to  the  Meatb 
Hospital.  In  one  vol.  8vo.,  cloth,  $2  50. 

A  TREATISE  ON  FEVER.  By  ROBERT  D.  LYOKP, 
K  C  C.  In  one  octavo  volume  of  362  pages,  cloth, 
*2  25. 


HENRY  C.  LSA'S  PUBLICATIONS — (  Venereal  Diseases, 


19 


DUMSTEAD  (FREEMAN  J.},  M.D., 

•*-*         Professor  of  Ven.fre.al  Diseases  at  the  Onl.  of  Phys  and  Sura. .  fff.w  YnrTt.  Ac. 

THE  PATHOLOGY  AND  TREATMENT  OF  VENEREAL  DIS- 

EASES-  Including  the  results  of  recent  investigations  upon  the  subject.  Third  edition, 
rerised  and  enlarged,  with  illustrations.  In  one  large  and  handsome  octavo  volume  of 
over  700  pages,  cloth,  $5  00  ;  leather,  $6  00. 

In  preparing  this  standard  work  again  for  the  press,  the  author  has  subjected  it  to  a  very 
thorough  revision.  Many  portions  have  been  rewritten,  and  much  new  matter  added,  in  order  to 
bring  it  completely  on  a  level  with  the  most  advanced  condition  of  syphilography,  but  by  care- 
ful compression  of  the  text  of  previous  editions,  the  work  has  been  increased  by  only  sixty-four 
pages  The  labor  thus  bestowed  upon  it,  it  is  hoped,  wilHneure  for  it  a  continuance  of  its 
position  as  a  complete  and  trustworthy  guide  for  the  practitioner. 

A  valuable  work  on  Venereal  Diseases,  which  not  I  venereal  diseases,  that  it  may  seem  almost  superfln- 


only  has  a  wide  circulation  in  this  country,  and 
been  accepted  as  the  standard,  but  appears  to  have 
formed  tlie  basis,  to  a  large  extent,  of  many  of  the 
books  and  articles  which  have  been  written  on  the 
same  subject  and  published  in  England.-  The  Glas- 
gow Mud.  Journ,,  Oct.  1877. 

It  is  the  most  complete  book  with  which  weare  ac- 
quainted in  the  language.  The  latest  views  of  the 
best  anthoritiesareput  forward,  and  the  information 
Is  well  arranged— a  great  point  for  the  student  and 
still  more  for  the  practitioner.  The  subjects  of  vis- 
ceral syphilis,  syphilitic  affections  of  theeyes,  and 
the  treatment  of  syphilis  by  repeated  inoculations, 
are  'ery  fully  discussed. — Land..  Lancet,  Jan.  7,  '71. 

Dr.  Bumstead's  work  is  already  so  universally 
known  as  the  best  treatise  in  the  English  language  on 


ons  to  say  more  of  it  than  that  a  new  edition  has  been 
issued.  But  the  author's  industry  has  rendered  this 
new  edition  virtually  a  new  work, and  so  merits  as 
much  special  commendation  as  if  its  predecessors 
bar  not  been  published.  As  a  thoroughly  practical 
book  on  a  class  of  diseases  which  form  a  large 
share  of  nearly  every  physician's  practice,  the  vol- 
ume beforr  us  is  by  far  the  best  of  which  we  have 
knowledge  .—If.  T.  'Medical  Gazette,  Jan.  28,  1871. 

It  is  rare  in  the  history  of  medicine  to  find  anyone 
book  which  contains  all  that  a  practitioner  needs  t  o 
know;  while  the  possessor  of  "Bumstead  on  Vene- 
real" has  no  occasion  to  look  ouMde  of  its  covers  for 
anything  practical  connected  with  thediagnosis.  his- 
tory, or  treatment  of  these  affections. — N.  Y.  Medi- 
na journal,  March,  1871. 


flULLERIER  (A.},  and         T>UMSTEAD  (FREEMAN  J.}, 

^^         Surgeon  to  the  Hdpital  du  Midi.  •*-*        Profeseor  of  Venereal  Disease,*  in  the  College  o] 

;•!*  *•<>•  i  ~     Physicians  aarf  Surgeons.  N.  Y 

AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  by 

FREEMAN  J.  BUMSTEAD.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns, 
with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 
life;  strongly  bound  in  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 
Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  THREE  DOL- 
LARS a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this   department  of 
practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 
delay.     A  specimen  of  the  plates  and  text  sent  free  by  mail,  on  receipt  of  25  cents. 


We  wish  for  once  that  our  province  was  not  re- 
strict d  to  methods  of  treatment,  that  we  might  say 
gome-.hing  of  the  exquisite  colored  plates  in  this 
volume.—  London  Practitioner,  May,  1869. 

As  a  whole,  it  teaches  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
IS,  1869. 

Superior  to  anythingof  the  kind  ever  before  issued 
on  this  continent. — GanadaMed.  Journal,  Mareh,'69 

The  practitioner  who  desires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published. — 
Dominion  Med.  Journal,  May,  1869. 

This  is  a  work  ofmaster  hands  on  both  sides.  M. 
Oullerier  is  scarcely  second  to,  we  think  we  may  truly 
say  is  a  peer  ofthe  illustrious  and  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  i?  without  a  rival 
Assuring  our  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 


to  Its  end,  we  do  not  know  a  single  medical  work, 
which  for  its  kind  is  more  necessary  for  them  to 
have.—  Galifornia  Med.  Gatette,  March,  1869. 

The  most  splendidly  illustrated  work  in  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
French  original.—  Am.  Jour.  Med.  Sciences,  Jan.'6&. 

The  fifth  and  concluding  number  of  this  magnificent 
wqrk  has  reached  us,  and  we  have  no  hesiiation  in 
saying  that  its  illustrations  surpassthose  pf previous 
aumbers.  —  Boat  Mud.  and  Surg.  J1.,  Jan.  14  1869. 

Other  writers  besides  M.  Cullerier  have  given  us  a 
good  account  of  the  diseases  of  which  he  treats,  but 
no  one  has  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases  There  is, 
however,  an  additional  interest  and  value  possessed 
by  the  volumebefore  UF;  foritisan  American  reprint 
and  translation  of  M.  Cullerier's  work,  with  inci- 
dental remarks  by  one  ofthe  most  eminent  Ameri- 
can syphilographers, Mr.  Bnmstead. — Brit .andFoi . 
Medico- Ohir.  Review,  July,  1869. 


TEE  (HENRY), 

-*-*        Prof,  of  Surgery  at  the  Royal  (lollege  of  Surgeon*  of  England,  etc. 

LECTURES  ON  SYPHILIS  AND  ON  SOME  FORMS  OF  LOCAL 
DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION.  In  one 
handsome  octavo  volume:  cloth;  $2  25.  (Lately  Published.) 

ulation;  the  modifications  of  these  processes  in  patients 


The  work  is  valuable,  as  it  treats  quite  fully  of  sub- 
jects which  are  not  dwelt  upon  in  the  systematic  works 
of  other  English  authorsof  the  present  day.  as  the  in- 
oculability  of  syphilitic  blood;  the  conditions  under 
which  the  secretions  of  primary  and  secondary  syphi- 
litic manifestations  may  be  inoculated  naturally  or 
artificial  ly ;  the  morbid  processes  produced  bs  such  inoc- 


previous'y  syphilitic;  primary  and  secondary  syphilitic 
diseases  ofthe  mucous  membranes  and  their  liability 
to  communicate  constitutional  syphilis,  etc.  The  book 
is  full  of  clinical  material  illustrating  these  topics, 
original  or  quoted. — Archives  of  Dermatology,  April, 
1876. 


TJ1LL  (BERKELEY], 

J~*-  Surgeon  to  the  Lock  Hospital,  London. 

ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

one  handsome  octavo  volume  ;  cloth,  $3  25. 


In 


20        HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  the  Skin,  £c.). 
POX  (TILBURY),  M.D.,F.R.C.P.,and  T.  C.  FOX,  B.A.,  M.R.C.S., 

Phynician  to  the,  Dep nrtme.nl  for  Skin  Dineastn,  UniwrKity  Colltgf  Honpitnl. 

EPITOME  OF  SKIN  DISEASES.    WITH  FORMULAE.     FOR  STU- 

DENTS  AND  PKACTiTioNKRS .    Second  edition,  thoroughly  revised  and  grently  enlarged.  In 
one  very  handsome  12mo.  volume  of  216  pages.     Cloth,  $1  38.     (Just  Ready.) 

PREFACE. 

In  preparing  this  edition  of  our  "EPITOME"  for  publication  in  the  United  States,  we  have 
increased  the  matter  to  about  three  times  its  original  amount.  The  kindly  appreciation  mani- 
fested for  the  work  by  the  American  profession  has  stimulated  us  to  spare  no  pains  in  rendering 
it  more  worthy  of  their  approbation,  and  in  its  enlarged  form  we  believe  that  it  will  be  found  of 
enhanced  value.  About  two-thirds  of  the  work  is  newly  written,  and  we  may  direct  attention 
particularly  to  the  section  regarding  the  Pathology  of  the  Skin,  which  has  been  entirely  recast. 
and  now  contains  a  concise  account  of  all  the  important  changes  taking  place  in  the  dermiil 
textures  in  disease.  The  clinical  descriptions  of  diseases  also  have  been  amplified  and  occasion- 
ally remodelled.  Lnstly,  we  may  say  that  in  adding  material  to  the  book  we  have  selected  such 
as  bears  on  the  practical  side  of  Dermatology,  to  the  exclusion  of  that  which  is  as  yet  hypo- 
thetical or  merely  of  interest  to  the  curious  student. 

The  favorable  reception  accorded  to  the  work  on  both  sides  of  the  Atlantic  would  seem  to 
show  that  it  has  realized  the  object  with  which  it  was  prepared — to  afford  assistance  to  the  stu- 
dent in  his  early  study  of  dermatology,  and  to  serve  as  a  manual  for  ready  reference  by  the 
practitioner  in  his  daily  practice.  For  this  latter  purpose  it  has  been  specially  adapted,  by 
means  of  the  references  made  in  the  sections  on  treatment  to  the  formula}  at  the  end. 


'ILSON  (ERASMUS),  F.R.S. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

BASES  OF  THE  SKIN.   In  one  very  handsome  royal  12mo.  volume.   $3  50. 

'ELIGAN  (J.MOORE),  M.D.,M.R.I.A. 
ATLAS  OF  CUTANEOUS  DISEASES.      In  one  beautiful  quarto 

volume,  with  exquisitely  colored  plates,  Ac.,  presenting  about  one  hundred  varieties  of 
disease.     Cloth,  $5  50. 

filLLIER  (THOMAS),  M.D., 

Physician  to  the  Skin  Department  of  University  College  Hospital,  etc. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 
Second  Am.  Ed.     In  one  royal  12mo.  vol.  of  358  pp.    With  Illustration;      Cloth,$225. 


We  can  conscientiously  recommend  it  to  the  stu- 
dent ;  the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  andthe  descriptions  of  disease,  with 
the  modes  of  treatment  recommended,  are  frequent- 
ly illustrated  with  well-recorded  cases. — London 
Mea.  Cimes  and  Gazette,  April  1,  1865. 


It  is  a  concise,  plain,  practical  treatise  on  the 
varous  diseases  of  the  skin  ;  just  such  a  work, 
indeed  as  was  much  needed,  both  by  medical  stu- 
dents and  practitioners.  —  Chicago  Medical  Ex- 
aminer, Ma)  1865. 


WEST  (CHARLES),  M.D., 

Physician  to  the  Hospital/or  Sick  Children,  London,  Ac. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILE- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volume  of  678  pages.    Cloth,  $4  50;  leather,  $5  50.  (Latr/y  Istued  ) 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into 
German,  French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a  want 
exten  jively  felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the 
authority  derived  from  a  more  extended  experience  than  Dr.  West,  and  his  work  now  presents 
the  results  of  nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from 
among  nearly  40,000  oases  which  have  passed  under  his  care.  In  the  preparation  of  the  pre- 
sent edition  he  has  omitted  much  that  appeared  of  minor  importance,  in  order  to  find  room  for 
the  introduction  of  additional  matter,  and  the  volume,  while  thoroughly  revised,  is  therefore 
not  increased  materially  in  size. 

Of  all  the  English  writers  on  the  diseases  of  chil-  I  highest  living  authorities  in  the  difficult  department 
dran,  there  is  no  one  so  entirely  satisfactory  to  us  |  of  medical  science  in   which  he    is   most  widely 
as  Dr.  West.    For  years  we  have  held  his  opinion  I  known.-  Boston  Xed.  and  Surg.  Journal. 
as  judicial,  and  have  regarded  him  as  one  of  the  | 

T5F  THE  SAME  AUTHOR.    (Lately Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.  In  one  volume  small  12mo.,  cloth,  $1  00. 

JgF  THE  SA.ME  AUTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.  Third  American, 
from  the  Third  London  edition.  In  one  neat  octavo  volume  of  about  550  pages,  clotl, 
$3  75 ;  leather,  $4  75. 


HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  Children').  21 

jgMITH(J.  LEWIS],  M.D., 

Clinical  Professor  of  Dixe.axe.*  of  Children  in  the  Bf.llf.vue  Hospital  Mrd    College,  2V  T. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  Edition,  revised  nnd  enlarged.     In  one  handsome  octavo  volume 
of  about  750  pages,  with  illustrations.     Cloth,  $4  50  ;   leather,  $5  50.      (Now  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  the  English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  respect  of  a  continuance  of  professional 
confidence.     Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materially 
increased. 

In  the  period  which  has  elapsed  since  the  third  '  It  is  scarcely  necessary  for  us  to  say  th»  work  be- 
edition  of  the  work,  so  extensive  have  been  the  ad-  fore  us  is  a  standard  work  upon  diseases  of  children, 
vanees  that  whole  chapters  required  to  be  rewritten,  and  that  no  work  has  a  higher  standing  tliau  it  upon 
aad  hardly  a  page  could  pass  without  some  material  those  affections.  In  consequence  of  its  thorough  re- 
correction  or  addition.  This  labor  has  occupied  the  -vinion,  the  work  has  been  made  of  more  value  than 
writer  closely,  and  he  has  performed  it  ci.nscien-  ever,  and  may  be  regarded  as  fully  abrenst  of  the 
tioasly,  so  that  the  book  may  be  considered  a  faith-  times.  We  cordially  commend  it  to  students  and 
ful  portraiture  of  an  exceptionally  wide  clinical  physicians  There  is"  no  better  work  in  the  language 
experience  in  infantile  diseases,  c  rrected  by  a  care-  on  diseases  of  children. — Cincinnati  Med.  Ntws, 
fttl  study  of  the  recent  literature  of  the  subject.—  March,  1879. 
Med.  and  Surg.  Reporter,  April  5,  1879. 


fjONDIE  (D.  FRANCIS],  M.D. 

A  PRACTICAL  TREATISE   ON   THE  DISEASES  OF  CHIL- 

dren.     Sixth  edition,  revised  and  augmented.     In  one  large  octavo  volume  oJ  nearly  800 
closely-printed  pages,  cloth,  $5  25  ;  leather,  $6  25. 


g WITH  (E USTA  CE),  M.  D., 

Physician  to  the  North 


Physician  to  the  Northwest  London  Free  T)ispp.nsary  for  Sick  Children. 

A  PRACTICAL  TREATISE  ON   THE~  WASTING   DISEASES  OF 

INFANCY    AND   CHILDHOOD.    Second  American,  from   the  second  revised  and  en- 
larged English  edition.  In  one  handsome  octavo  volume,  cloth,  $2  50.   (Lately  Issued.) 


(JOSEPH  GRIFFITHS],  M.D., 

Physician-  Accoucheur  to  the.  British  General  Hospital,  Ac. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 

MENCING  MIDWIFERY  PRACTICE  Second  American,  from  the  Fifth  and  Revised 
London  Edition,  with  Additions  by  E.  R.  HDTCHINS,  M.D.  With  Illustrations.  In  one 
neat  12mo.  volume.  Cloth,  $1  25.  (Lately  Issued.) 

#**  See  p,  4  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
subscribers  to  the  "  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES." 


CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASESPECULIARTO  WOMEN.  1vol. 
Svo.,  pp.  4f>0,  cloth  $250. 

DEWEES'S  TREATISE  ON  THE  DISEASES  OF  FE- 
MALES. With  illustrations.  Eleventh  Edition, 
with  the  Author's  lastimprovements  and  corrf  o- 
tlons.  In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.  $3  00. 


MEIGS  ON  THE  NATURE,  SIGNS.  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  1  vol.  Svo  ,  pp. 

365^  cloth      $200. 

ASHWELL'S  PRACTICAL  TREATISE  ONTHEDU- 
EASES  PECULIAR  TO  WOMEN.  Third  American, 
from  the  Third  and  revised  London  edition.  1  vo!. 
Svo. ,  pp.  528,  cloth.  $350. 


JJODOE  (HUGH  L.],  M.D., 

Emeritus  Professor  of  Obstetrics,  &c.,  in  the  University  of  Pennsylvania . 

ON  DISEASES  PECULIAR  TO  WOMEN  ;  including  Displacements 

of  the  Uterus.     With  original  illustrations.    Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 


Professor  Hodge's  work  is  truly  an  original  one 
from  beginning  to  end,  consequently  no  one  can  pe- 
ruse its  pages  without  learning  something  new.  At  a 


contribution  to  the  study  of  women's  diseases,  it  is  rf 
great  value,  and  is  abundantly  able  to  stand  on  its 
own  merits.— N.  Y.  Mtdical  Record,  Sept.  15,  1861- . 


(FLEETWOOD],  M.D.,  M.R.I.A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  additiots 
by  D.  FRANCIS  CONDIE,  M.D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Chil- 
dren," Ac.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octavo 
volume  of  nearly  700  large  pages.  Cloth,  $4  00  ;  leather,  $5  00. 


MONTGOMERY'S  EXPOSITION  OF  THE  SIGNS 
AND  SYMPTOMS  OF  PREGNANCY.  With  two 
exquisite  colored  plates,  and  numerous  wood  cuts. 
In  1  vol.  8vo.,ofnearly  600pp., cloth,  $3  75. 


RIGBY'8  SYSTEM  OF  MIDWIFERY.  With  notes 
and  Additional  Illustrations.  Second  Ameriian 
edition.  One  volume  octavo,  cloth,  422  pages, 
$250. 


2-2 


HENRY  C.  LEA'S  PUBLICATIONS—  (Diseases  of  Women). 


fflOMAS  (T.GAILLARD},M.D., 
Pro/c.ssor  of  Obstetrics,  Ac.,  in  the  Collage  of  Physicians  and  Surgeons,  N.  T.,  Ac 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Fourth 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of 

800  pages,  with  191  illustrations.     Cloth,  $5  00  ;  leather,  $6  00.     (Just  Issued.) 

The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 

this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 

received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 

spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 

A  work  which  has  reached  a  fourth   edition,  and  i  is  classical  withontbeingpedantic.fnll  in  Ihedetails 

that.  too.  in  the  short  space  of  five  years,  has  achieved  !  of    anatomy    and    pathology,    without  ponderous 

a  reputation  which  places  it  almost  beyond  the  reach    translation  of  pages  of  German  literature,  describes 

of  criticism,  and  the  favorable  opinions  which  we  have    distinctly  the  details  and  difficulties  of  each  opera- 

a'ready  expressed  of  the  former  editions  seem  to  re-    tion,  without  wearying  and  useless  minutije,  and  is 

quire  that  we  should  do  little  more  than  announce  ]  in  all  respecTVji  work  worthy  of  confidence,  justify- 

this  new  issue.     We  cannot  refrain  from  saying  that,    ing  the  high  regard  in  which  its  distinguished  au- 

as  a  practical  work,  this  is  second  to  none  in  the  Eng-  !  thor  is  held  by  the  profession.—  Am.  Supplement, 

lish,  or.  indeed,  in  any  other  language.    The  arrange- 1  Obstet.  Journ.,  Oct.  1874. 

ment  of  the  contents,  the  admirably  clear  manner  in  j      ProfesgorThomasfairly  took  the  Profession  of  the 

Vn  K.  !  United  States  by  storm  when  his  book  first  made  it* 


very  clear  head  and  decided  views,  and  there  seems  to 
be  nothing  which  he  so  much  dislikes  as  hazy  notions 
of  diagnosis  and  blind  routine  and  unreasonable  thera- 
peutics. The  student  who  will  thoroughly  study  thin 
b  >ok  and  test  its  principles  by  clinical  observation,  will 
certainly  not  be  guilty  of  these  faults. — London  Lancet, 
Feb.  13,  1875 

Reluctantly  we  are  obliged  to  close  this  unsatis- 
factory notice  of  so  excellent  a  work,  and  in  concln- 
sion'would  remark  that,  as  a  teacher  ofgynsecology, 
both  didactic  and  clinical,  Prof.  Thomas  has  certainly 
taken  the  lead  far  ahead  of  his  confreres,  and  as  an 
author  he  certainly  has  met  with  unusual  and  mer- 
ited success. — Am  Journ.  of  Obstetrics,  Nov.  1874. 

This  volume  of  Prof.  Thomas  in  its  revised  form 


second  one  was  issued,  and  in  two  years  a  third  one 
was  announced  and  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 
not  ephemeral,  and  itssuccess  wasunprecedentedin 
the  annalsof  American  medical  literature.  Six  years 
U  a  long  period  in  medical  scientific  research,  but 
Thomas's  work  on  "  Diseases  of  Women"is  still  the 
leading  native  production  of  the  United  States.  The 
order,  the  matter,  the  absence  of  theoretical  dispir  a- 
tiveness,  the  fairness  of  statement,  and  the  elegance 
of  diction,  preserved  throughout  the  entire  range  of 
the  book,  indicate  that  Professor  Thoma*  did  not 
overestimate  his  powers  when  he  conceived  the  idea 
and  executed  the  work  of  producing  a  new  treatise 
upon  diseases  of  women. — PROF.  P ALLEN,  in  Louit- 
ville  Sfed.  Journal,  Sept.  1874. 


ftARNES  (ROBERT),  M.D.,  F.R.C.P., 

•*-*  Obstetric  Physician  to  St.  Thomas's  Hoi-pit al,  *e. 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  Inon*  handsome  octavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  $4  50;  leather,  $5  50.  (Just  Ready.) 

The  call  for  a  new  edition  of  Dr.  Barnes's  work  on  the  Diseases  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profession  than  before.  By  a  rear- 
rangement and  careful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gynaecological 
Relations  of  the  Bladder  ani  Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introduced  where  experience  has  shown  them  to  be  needed.  It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynaecological  science. 

Dr  Barnes  stands  at  the  head  of  his  profession  in  the  work  is  a  valuable  one,  and  should  be  largely 
the  old  country,  and  it  requires  but  scant  scrutiny  |  consulted  by  the  profession. — Am.  Siipp  Obstetrical 
of  his  hook  to  show  that  it  has  been  sketched  by  a  I  Journ.  Gt.  Britain  and  Ireland,  Oct.  1878. 


master.     It  is  plain,  practical  common  sense  ;  shows 
very  deep  research  without  being  pedantic  ;  is  emi- 


No  other  gynaecological  work  holds  a  higher  posi- 
tion, having   become   an   authority  everywhere  in 


nently  calculated  to  inspire  enthusiasm  without  in-  dlseases  of  women.  The  work  has  been  brought 
culcating  rashness;  points  out  the  dangers  to  be  fnl,  abreast  of  present  knowledge.  Every  practi- 
avoid,-d  as  well  as  the  success  to  be  achieved  in  the  tioner  of  medicine  ghould  have  it  upon  the  shelves 
various  operations  connected  with  th.s  branch  of  of  his  lib rary  and  the  8tudent  will  find  it  a  superior 
medicine;  and  will  do  much  to  smooth  the  rugged  t«t-book.-«nc<n»a«  Med.  News,  Oct.  1S7S. 
path  of  the  young  gynaecologist  and  relieve  the  per-  | 


plexity  of  the   man   of  mature  years.  —  Canadian 
Journ.  of  Med.  Science,  Nov.  1878. 


This  second  revised  edition,  of  course,  deserves  all 
the  commendation  given  to  its  predecessor,  with  the 
additional  one  that,  it  appears  to  include  all  or  nearly 
We  pity  the  doctor  who,  having  any  consider-  '  all  the  additions  to  our  knowledgeof  its  subject  that 
aMe  practice  in  diseases  of  women,  has  no  copy  of  have  been  made  since  the  appearance  of  the  first  ecli- 
•'  Barnes"  for  dailv  consultation  and  instruction.  It  tion  The  American  references  are.  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  |  work,  especially  full  and  appreciative,  and  we  can 
individual  experience,  and  at  the  same  time  emi-  ,  cordially  recommend  the  volume  to  American  read- 
nently  practical.  That  it  has  been  appreciated  by  '  ers  — Journ.  of  Nervous  and  Mental  Disease,  O«t. 
the  profession,  both  in  Great  Britain  and  in  this  ;  187S. 

country,  is  shown  by  the  second  edition  following  <      Thig  gecona   edition  of  Dr.  Barnes's  great  work 
so^oon   upon   the   first.— Am.   Practitioner,   Nov.    comes  to  ng  c(,ntaining  many  additions  and  improve- 
ments which  bring  it  up  to  date  in  every  feature. 


Dr  Barnes's  work  is  one  of  a  practical  character,  |  The  excellences  of  the  work  are  too  well  known  to 
largely  illustrated  from  cases  in  his  own  experience,  i  require  enumeration,  and  we  hazard  the  prophecy 
bat  by  no  means  confined  to  such,  as  will  be  learned  <  that  they  will  for  many  years  maintain  its  high  po- 
£rom  the  fact  that  he  quotes  from  no  lets  than  628  ;  sition  as  a  standard  text-book  and  guide  book  for 
medical  authors  in  numerous  countries.  Coming  1  students  and  practitioner*.  —  If.  O.  Mtd.  Journ., 
from  such  an  author,  it  is  not  necessary  to  say  that  ,  Oct.  1878. 


HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  Women).  23 

PMMET  (THOMAS  ADDIS}.  M.D. 

•*-*  Surgeon  to  thr.  Woman's  H>*pita>,  \no  York.  tt". 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNAECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.  In  one  large  and  very  handsome  octavo 
volume  of  850  pages,  with  130  illustrations.  Cl  th.  $5;  leather,  $('>.  (J/ttt  Ready.) 
Dr  Emmet  is  so  widely  known  as  among  the  most  eminent  of  those  who  have  made  gynae- 
cology a  peculiarly  American  science  that  the  profession  cannot  fail  to  welcome  a  work  in  which 
he  has  condensed  the  results  of  his  long  and  extensive  experience.  He  has  sought  to  consider 
the  whole  subject  of  the  diseases  peculiar  to  females  in  a  manner  which  will  adapt  the  volume, 
not  only  to  the  wants  of  the  student  as  a  text  book,  but  to  those  of  the  practitioner  as  an  aid  in 
the  emergencies  of  daily  practice.  A  special  feature  of  the  work  will  be  f  >und  in  the  numerous 
condensed  tables,  which  convey  at  a  glance,  and  within  the  narrowest  compass,  the  conclusions 
to  be  drawn  from  the  many  thousand  cases  which  have  passed  under  the  care  of  the  author. 
With  trifling  exceptions,  the  illustrations  are  all  original,  and  the  volume  will  be  found  in  every 
point  of  typographical  execution  worthy  of  the  distinguished  position  which  is  confidently  anti- 
cipated for  it. 


(JAMES  R.},  A.M.,  M.D. 
A  MANUAL  OF  THE    DISEASES  PECULIAR  TO  WOMEN.    In  one 

neat  volume,  royul  12mo  ,  with  illustrations.      (Preparing.) 

America  has  contributed  so  largely  to  the  advances  which  have  made  the  treatment  of  Dis- 
eases of  Women  a  distinctive  department  of  medical  science,  that  the  student  will  naturally 
turn  to  American  Books  for  the  latest  and  most  trustworthy  instruction  on  the  subject  in  its 
most  modern  aspeot.  Yet  there  has  thus  far  been  no  attempt  in  this  country  to  produce  a  handy 
manual,  presenting  in  a  condensed  and  convenient  form  the  information  requisite  for  the  learner 
or  for  the  general  practitioner.  This  want  it  has  been  the  effort  of  Dr.  Chadwick  to  supply,  and 
the  special  attention  which  he  has  devoted  to  the  subject  is  a  guarantee  of  the  value  of  his  labors. 
A  distinguishing  feature  of  the  work  will  be  a  number  of  diagrammatic  illustrations,  facilitating 
greatly  the  comprehension  of  the  text. 


Professor  and  Director  of  the  Gynaecological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 

MENT  OF  CHILDBED,  for  Students  and  Practitioners.     Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  JAMES  RKAD  CHADWICK,  M.D.    In 
one  octavo  volume.     Cloth,  $4  00.      (Lately  Issued.) 
This  work  wa*  written,  as  the  author  tells  us  in  hi.-,    ready  in  the  field,  and  the  present  standpoint  of  sci- 


preface.  to  supp  y  a  waut  arising  from  the  very  hriel 
consideration  j^iven  to  puerperal  diseases  l>y  writers 
on  Obstetrics,  in  which  rospeot  it  seems  the  profession 
in  his  country  is  not  different  from  ours,  nnd  to  fill  a 
blank  left  between  the  treaties-  upon  tl'e  subject  al- 


ence.  The  work  has  reached  a  second  I'dition,  and 
bears  evjdenc*  throughout  of  careful  study  and  prac- 
tical experience.  As  its  title  implies.it  is  u  manual 
rather  than  a  treatise. — American  Journal  oJJUid.  Sci- 
ences, April,  1ST  I. 


ITHE  OBSTETRICAL  JOURNAL.     (Free  of  postage  for  1879.) 

THE  OBSTETRICAL  JOURNAL  of  Great  Britain  and  Ireland; 

Including  MIDWIFERY,  and  the  DISEASES  OF  WOMEN  AND  INFANTS.  With  an  American 
Supplement,  edited  by  J.  V.  INCH  AM,  M.D.  A  monthly  t>f  about  96  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  1873,  the  Obstetrical  Journal  consists  of  Original  Papereby  Brit- 
ish and  Foreign  Contributors  ;  Transactions  of  the  Obstetrical  Societies  in  England  and 
abroad.  Reports  of  Hospital  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and 
Notes,  Editorial,  Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Cor 
respondence,  Ac  Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this 
important  and  rapidly  improving  department  of  medical  science,  the  value  of  the  infor- 
mation which  it  presents  to  the  subscriber  may  be  estimated  from  the  character  of  the  gen- 
tlemen who  have  alreadj  promised  their  support,  including  such  names  as  those  of  Drs.  AT- 
THILL,  AVELING,  ROBERT  BARNES,  J.  HENRI  BENNET,  NATHAN  BOZEMAN,  THOMAS  CHAMBERS, 
FLEETWOOD  CHURCHILL,  CHARLES  CLAY,  JOH*  CLAY,  MATTHEWS  DUNCAN,  ARTHUR  FADRE, 
ROBERT  GREENHALGH,  GRAILY  HEWITT,  BRAXTON  HICKS,  ALFRED  MEADOWS,  W.  LEISH- 
MAN,  ALEX.  SIMPSON,  HEYWOOD  SMITH,  TYLER  SMITH,  EDWARD  J.  TILT,  LAWSON  TAIT, 
SPENCER  WELLS,  Ac.  Ac.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Gynae- 
cology. 

In  order  to  render  the  OBSTETRICAL  JOURNAL  fully  adequate  to  the  wants  of  the  Ameri- 
can profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstet- 
rics and  Gynfficology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under 
the  editorial  charge  of  Dr  J.  V.  INGHAM,  to  whom  editorial  communications,  exchanges, 
books  for  re7iew,  Ac.,  may  be  addressed,  to  the  care  of  the  publisher. 

%*  Complete  set?  from  the  beginning  can  no'longer  be  furnished,  but  subscriptions  can 
conrnence  wi^h  January,  1879,  or  Vol.  VII.,  No  1,  April,  1879. 


HENRY  C.  LEA'S  PUBLICATIONS — (Midwifery}. 


pLAYFAIR  (  W.  S.),  M.D.,  F.R.C.P., 

Prnfessor  of  Obstetric  Medicine,  in  King's  College, etc.  etc. 

A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Second  American,  from  the  Second  and  Revised  English  Edition.  Edited,  with  Addi- 
tions, by  ROBEKT  P.  HARIUS,  M.D.  In  one  handsome  octavo  volume  of  639  pages,  with 
182  illustrations.  Cloth,  $4  00;  Leather,  $5.00.  (Just  Ready.) 

In  reprinting  this  work  from  the  second  London  edition,  the  position  which  it  has  assumed 
in  this  country  as  an  authoritative  text-book  seemed  to  call  for  such  additions  as  would  render 
it  more  completely  suited  to  the  wants  of  the  American  student.  A  careful  scrutiny  on  the  part 
of  the  editor  has  shown  that  but  little  was  required  for  this  purpose  ;  the  work,  though  condensed, 
being  very  complete  and  accurate.  With  the  exception  of  numerous  short  foot-notes,  therefore, 
his  additions  have  been  confined  to  points  in  which  the  experience  and  practice  of  American 
obstetricians  differ  from  those  of  England,  and  to  one  or  two  matters  of  recent  interest.  These 
are  chiefly  the  Cffisarean  Section  ;  the  varieties  of  forceps,  and  their  use  in  the  dorsal  decubitus; 
dystocia  from  tetanoid  uterine  constriction;  and  the  intra-venous  injection  of  milk,  as  a  substi- 
tute for  the  transfusion  of  blood. 

The  position  which  this  work  has  so  qu'ckly  taken 
in  this  country  as  an  authoritative  text-book  renders 
any  extended  consideration  of  its  plan  and  scope 
unnecessary.  Its  merits,  which  are  many,  have  al- 
ready found  their  way  to  the  appreciation  of  students 
and  practitioners  alike  in  the  length  and  breadth  of 
the  land.—  Am.  Supp.  Obitet.  Journ.  of  Ot.  Britain 
and  Ireland,  Oct.  1878. 

This  excellent  text-book  has  been  submitted  to  a 
thorough  and  careful  revision,  and  will  be  found 
fully  up  to  the  times  in  every  department.  The 
notes  by  the  American  editor  enhance  the  value  of 
the  work  for  the  American  student.  Those  on  the 
use  of  forceps  are  particultrly  good,  and  constitute 
by  themselves  a  valuable  chapter. — N.  Y.  Med. 
Journ.,  Nov.  1878. 

The  best  work  on  the  subject  ever  published  in  the 
English  language.  It  is  written  iu  a  clear,  pleasant 
style,  without  that  verbosity  which  characterizes 
some  modern  and  highly  pretentious  works.  The  au- 
thor is  quite  up  with  the  times,  both  in  practice  and 


theory.    It  is  the  best  text-book  we  have  for  students, 


Probably  this  is  the  very  best  and  most  useful 
manual  of  midwifery  now  available  to  the  profes- 
sion. Itis  written  in  lucid,  scholarly  English,  which 
some  of  our  cis-Atlantic  writers  would  do  well  to 
imitate.  There  has  been  no  attempt  to  swell  the 
magnitude  of  the  work  by  fine  writing,  or  by  lengthy 
discussions  ofobtcure  points  of  which  no  trustworthy 
solution  has  yet  been  reached  ;  on  the  contrary,  the 
tendency  is  throughout  obviously  towards  simplic- 
ity. The  chapter  upon  the  Mechanism  of  Labor 


is  divested  01  tnose  leature.s  wnicn  in  ainiosi  every 
other  work  we  know  lets  only  darkness  instead  of 
light  in  upon  the  subject. — -tf.  O.  Med.  Journ.,  Oct. 
1878. 


H 


'ODGE  (HUGH  L.),  M.D., 

Emeritus  Professor  of  Midwifery,  &c.,  in  the  University  of  Pennsylvania,  Ac. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.  Illus- 
trated with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something  more  than  i  subject  ills  decidedly  the  best. — Edinb.  Med.  Jour., 
a  simple  presentation  of  his  particular  views  in  the    Dec.  1864. 


department  of  Obstetrics;   it  is   something  more 
than  an  >rdinary  treatise  on  midwifery;  it  is,  in  fact, 


We   have   read    Dr.    Hodge's   book  with   great 
pleasure,  and  have  much  satisfaction  in  express- 


a  cyclopaedia  of  midwifery.  He  has  aimed  to  em-  j  ing  our  Commendation  of  it  as  a  whole.  It  is  cer- 
body  in  a  tingle  volume  the  whole  science  and  art  of;  tainly  highly  instructive,  and  in  the  main,  we  be- 
Obstetrics.  An  elaborate  text  is  combined  with  ac-  lieve  correct.  The  great  attention  which  the  au- 
curate  and  varied  pictorial  illustrations,  so  that  no  |  thor  hag  devoted  to  tee  mechanism  of  parturition, 
fact  or  principle  is  left  unstated  or  unexplained,  taken  along  with  the  conclusions  at  which  he  has 


— Am.  Med.  Times,  Sept.  3,  1864. 


arrived,  point,  we  think,  conclusively  to  the  fact 


It  IB  very  large,  profusely  and  elegantly  illnstrat-l  that,  in  Britain  at  least,  the  doctrines  of  Naegele 
ed,  and  is  fitted  to  take  its  place  near  the  works  of  i  have  been  too  blindly  received. — Glasgow  Med. 
great  obstetricians.  Of  the  American  works  on  the  I  Journal,  Oct.  1864. 

%*%  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


/TANNER  (THOMAS  H.),  M.D. 

ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


ffAMSBOTHAM  (FRANCIS  H.),  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  KEATING,  M.  D., 
Professor  of  Obstetrics,  Ac.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  lurjre 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.  $7  00. 


HENRY  C.  LEA'S  PUBLICATIONS — (Midwifery,  Surgery*). 


25 


TEISHMAN  (WILLIAM],  M.D., 

^~^  Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  &c. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Second  American,  from  the  Second 
and  Revised  English  Edition,  with  additions  by  JOHN  S.  PAURY,  M.D.,  Obstetrician  to  the 
Philadelphia  Hospital,  Ac.  In  one  large  and  very  handsome  octavo  volume  of  over  700 
pages,  with  about  two  hundred  illustrations  :  cloth,  $5  ;  leather,  $6.  (Just  Issued.) 
That  this  book  is  recommended  as  a  text-book  by  I  added  (Dr.  P.  has  had  unusual  experience  in  this  form 
many  of  the  leading  scholars  of  medicine  in  this  of  puerperal  fever),  and  also  a  number  of  illustrations 


country,  is  sufficient  evidence  of  the  favor  in  which 
it  is  held.  In  a  word,  we  know  of  no  better  book  iu 
oar  language,  both  for  the  student  and  practitioner. 
The  value  of  the  book  is  enhanced  by  this  second 
edition,  which  contains  many  notes  by  our  late  Dr. 
Parry. — Chicago Med.Journ.  and  Examiner,  March. 
1877. 

But  the  most  valuable  additions  to  the  volume  are 
those  made  by  the  American  editor.  One  of  the  best  tests 
of  a  man's  ability  is  for  him  to  take  a  standard  work  in 
our  profession,  like  this  of  Dr.  Leishman,  and  materially 
Improve  it.  Many  a  one,  with  more  ambition  than  wis- 
dom, has  attempted  it  with  other  books  and  failed.  But 
Dr.  Parry  has  succeeded  most  admirably.  We  know  no 
obstetrical  work  that  has  anything  better  on  the  use  of 
the  forceps  than  that  which  Dr.  Parry  has  given  in  this, 
and  no  work  that  has  the  rational  and  intelligent  views 
upon  lactation  with  which  hehasenriched  this.  Having 
used  "Leishman"  for  two  years  as  a  text- book  for  stu- 
dents,we  can  cordially  commend  it.  and  are  quite  satisfied 
to  continue  such  use  now. — Am.  Practitioner,  Mar.  1876. 

This  new  edition  decidedly  confirms  the  opinion  which 
we  expressed  of  the  first  edition  of  the  work,  in  the  M«y. 
1874,  number  of  this  Journal,  that  this  is  "the  best 
modern  work  on  the  subject  in  the  English  language." 
The  excellent  practical  notes  contributed  by  Dr.  Parry 
refer  principally  to  the  use  of  the  forceps,  lactation,  and 
the  puerperal  diseases,  and  are  intended  to  increase  the 
useful  ness  of  the  work  in  this  country.  An  entirely  new 
chapter  on  diphtheria  of  puerperal  wounds  has  been 


of  the  principal  obstetrical  instruments  in  usein  Ame- 
rica. We  have  no  hesitation  in  saying  thatthe  work,  in 
its  present  shape,  is  a  great  improvement  on  its  prede- 
cessor, and  in  recommending  it  as  the  one  obstetrical 
text- book  which  we  should  advise  every  English  speak- 
ing practitioner  and  student  to  buy. — American  Jour- 
nal of  Obstetrics,  Feb.  1876. 

Perhaps  the  most  useful  onethe  student  can  procure. 
Some  important  additions  have  been  made  by  the  editor, 
in  order  to  adapt  the  work  to  the  profession  in  this  coun- 
try, and  some  new  illustrations  have  been  introduced, 
to  represent  the  obstetrical  instruments  generally  em- 
ployed in  American  practice.  In  its  present  form,  it  is 
an  exceedingly  valuable  book  for  both  the  student  and 
practitioner. — New  York  Med.  Journal,  Jan.  1876. 

Since  the  publication  of  Tyler  Smith's  lectures  on 
midwifery,  no  text  book  which  was  in  reality  the 
exponent  of  British  practice  has  appeared  in  the 
English  language  until  Dr.  Leishman  supplied  the 
want  by  his  system  of  midwifery,  which  was  pub- 
lished about  three  years  ago.  The  chief  feature  in 
this  work  is  the  exactness  in  description  of  the  me- 
chanism of  labor  ;  it  exhibits  most  accurate  obser- 
vation, and  is  a  perfect  analysis  of  the  subject,  it  is 
clear,  precise  and  masterly.  The  work  is  in  every 
way  a  valuable  addition  to  the  works  already  be- 
fore the  profession  on  the  science  and  practice  of 
obstetrics,  and  will,  we  doubt  not,  be  the  favorite 
text-book  used  in  our  schools. — Canada  Med.  and 
Surg.  Journal,  Nov.  1876. 


PARRY  (JOHN  s.),  M.D., 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-Prest.  of  the  Obstet.  Society  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND   TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  60.     (Lately  Issued.) 

This  work,  being  as  near  as  possible  a  collection  of  th  e 


In  this  work  Dr.  Parry  has  added  a  most  valuable 
contribution  to  obstetric  literature,  and  one  which 
meets  a  want  long  felt  by  those  of  the  profession  who 
have  ever  been  called  upon  to  deal  with  this  class  of 
cases. — Boston  Med.  and  Surg.  Journ.,  March  9, 1876. 


experiences  of  many  persons,  will  afford  a  most  useful 
guide,  both  in  diagnosis  and  treatment,  for  this  most 
interesting  and  fatal  malady.  We  think  it  should  be  in 
the  hands  of  all  physicians  practising  midwifery. —  Cin- 
cinnati Clinic,  Feb.  5,  1876. 


GT1MSON  (LEWIS  A.},  A.M.,  M.D., 

k3  Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  50.  (Now  Ready.) 


The  work  before  u»  is  a  well  printed,  profusely 
illustrated  manual  of  over  four  hundred  and  seventy 
pages.  Tbe  novice,  by  a  perusal  of  the  work,  will 
gain  a  good  idea  of  the  general  domain  of  operative 
surgery,  while  the  practical  surgeon  has  presented 
to  him  within  a  very  concise  and  intelligible  form 
the  latest  and  most  approved  selections  of  operative 
procedure.  The  precision  and  conciseness  with  which 
the  different  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
information  in  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3,  1878. 


performing  them.  The  work  is  handsomely  illus- 
trated, and  the  descriptions  are  clear  and  well  drawn. 
It  is  a  clever  and  useful  volume;  every  student 
should  possess  one.  The  preparation  of  this  work 
does  away  with  the  necessity  of  pondering  over 
larger  works  on  surgery  for  descriptions  of  opera- 
tions, as  it  presents  in  a  nut-shell  just  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to  find 
it.—  Md.  Med  Journal,  Aug.  1878. 

The  author's  conciseness  and  the  repleteness  of 
the  work  with  valuable  illustrations  entitle  it  to  be 
classed  with  the  text-books  for  students  of  operative 


This  volume  is  devoted  entirely  to  operative  sur-  |  surgery,  and  as  one  of  reference  to  the  practitioner, 
gery,  and  is  intended  to  familiarize  the  student  with  i  — Cincinnati  Lancet  and  Clinic,  July  27,  1878. 
the  details  of  operations  and  the  different  modes  of  i 


SKEY'S  OPERATIVE  SUKGEKY.  In  1  vol.  8vo. 
el.,  of  650  pages;  with  about  100  wood-cats.  $3  26 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  or  SURGERY.  Inl  vol.  Svo.cl'h,  750  p.  $2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
GERY. Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000 pp., leather,  raised  bands.  $6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  WILLIAM  PIRRIB,  F.R.S.E.,  Profes'r of  Surgery 
n  the  University  of  Aberdeen.  Edited  by  JOHN 


NEILL,  M.D.,  Professor  of  Surgery  In  the  Pecca. 
Medical  College,  Surg'n  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  $3  75. 

MILLER'S  PRTMCIPLESOF  SURGERY.  Fourth  Ame- 
rican, from  the  Third  Edinburgh  Edition.  In  one 
large  8vo.  vol.  of  700  pages,  with  340  illustrations, 
cloth,  $376. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Edition  Revised  by 
the  American  editor.  In  onelargeSvo.  vol. of  nearly 
700  pages,  with  364  illustrations :  cloth,  $3  75. 


HENRY  C.  LEA'S  PUBLICATIONS — '.Surgery  . 


SI  ROSS  (SAMUEL  D.),  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:    Pathological,  Diagnostic,  Therapeutic, 

and  Operative.    Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.    Fifth  edition 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15.    (Just  Issued.} 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
thi  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  to  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  nearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very 
moderate  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  of 
matter  is  Jondenseti  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind 
ing  renderf,  it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly 
belonging  to  the  iomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 

We  have  now  brought  our  task  to  a  conclusion,  and  elition  of  Oro»-'s  "  Surgery,"  will  confirm  his  title  of 
have  seldom  read  a  work  with  the  practical  value  of 
which  we  have  been  more  impressed.  Kvery  chapter  is 
BO  concisely  put  together,  that  the  busy  practitioner, 
when  in  difficulty,  can  at  once  find  the  information  he 
requires.  His  work,  on  the  contrary,  is  cosmopolitan, 
the  surgery  of  the  world  being  fnlly  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical,  that  it  is  almost  a  false  compli 


a  foremost  place  as  a  work  of  reference,  while  a  system 
of  surgery  like  the  present  system  of  surgery  is  the 
practice  of  *urge.on«.  The  printingand  binding  of  the 
work  is  unexceptionable;  indeed.it  contrasts,  in  the 
latter  re-speet.  remarkably  with  Enelish  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re- binding  before 
they  are  any  time  in  use. — Dub.  Journ.  of  M(d.  Sci.. 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actual  number  of  pages  is  not  more 
than  130,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  "ele- 
phant."there  has  been  room  for  considerableadditions, 
which,  together  with  the  alterations,  are  improve- 
ments.— Lond.  Lancet,  Nov.  16, 1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 


Primus  int^r  fur**."  It  is  learned,  scholar-like. 
thodical.  precise,  and  exhaustive.  We  scarcely  think 
any  living  man  could  write  co  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  mu.st  have 
been  immense,  and  the  work  gives  evidence  of  great 
powers  of  mind,  and  the  highest  order  of  intellectual 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience  — A'.  Y. 
Med.  Journ..  Feb.  1873. 

As  awhole.we  regard  the  work  astherepresentative 
"System  of  Surgery"  in  the  English  language. — St- 
Louis  Medical  and  Surg.  Jmtrn.,  Oct.  1872. 

The  two  magnificent  volumes  before  us  afford  a  veiy 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor.and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners desirousof enriching theirlihrnry  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancetand  O^s'.rvr.r,  Sept.  1«72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  ascientific  account  of  surjjiral'theorv 
and  practice  in  all  its  departments. — Brit,  and  For. 
Mfd  C/itr.  Ret).,  Jan.  1873. 


B 


Y  TBE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE   ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  SAMUEL  W.  GROSS,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.  In  one  handsome  octavo  volume  of  674  pages,  with  170  illus- 
trations: cloth,  $4  50.  (Just  Issued.) 


For  reference andgeneral  information,  the  physician 
or  surgeon  can  find  no  work  that  meets  their  necessities 
more  thoroughly  than  this,  a  revised  edition  of  an  ex- 
cellent treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustrations  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended,  by  the  reasonable  and  practical  manner 
in  which  the. various  subjects  are  syotematized  and 
arranged  We  heartily  recommend  it  to  the  profession 
»c  a  valuable  addition  to  the  important  literature  of  dis- 


eases of  the  urinary  organs. — Atlanta  Med.  Journ..  Oc*. 
1876. 

It  is  with  pleasure  we  now  again  take  up  this  old 
work  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  Th« 
chapters  on  -'Diseases  of  the  Hladder,"  "I'rostate 
Body,"  and  "Lithotomy,"  are  splendid  specimen ...  ,.f 
descriptive  writing;  while  the  chapter  on  "Stricture'' 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — Netc  York  Med.  Journ.,  Nov.  1876. 


THE 


T>T  THE  SAME  AUTHOR. 

A   PRACTICAL   TREATISE    ON   FOREIGN   BODIES    IN 

AIR-PASSAGES.     In  1  vol.  8vo.,  with  illustrations,  pp   468,  cloth,  $     75. 

T)RUITT  (ROBERT),  M.R.  C.S.,  &c. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illn»- 
trated  with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octaTo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire — Dublin  Quarterly  Journal. 

It  IB  a  most  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Sury.  Journal. 

In  Mr.  Drnitt'sbook,  though  containingonly  some 
seven  hundred  pages,  both  the  principles  and  the 


iractice  of  surgery  are  treated,  and  so  clearly  and 
>erspicuously,  as  to  elucidateeveryimportan  t  to  pit  . 
We  have  examined  thebook  most  thoroughly,  and 
can  <ay  that  this  success  is  well  merited.  Hit  bock 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  acd 
clarified  and  of  being  written  in  a  style  at  once 
clear  md  succinct. — Am.  Journatof  Med.  Science*. 


HENRY  C.  LEA'S  PUBLICATIONS — (Surgery}. 


A  SHHURST  (JOHN,  Jr.),  M.D., 

•*•••  Prof,  of  Clinical  Surgery,  Univ.  of  Pa..,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia 

THE   PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition,  enlarged  and  revised.     In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illustrations.     Cloth,  $6  ;  leather,  $7.      (Just  Ready.) 
Conscientiousness  and  thoroughness  are  two  very        Ashhuru's   Surgery  is   too   well    known    in   this 
marked   traits  of  character  in    the   author  of  this     country  to  require  special    commeudatiou  fr«ni  us 
book.     Out  of  these  traits  largely  has   grown    the     This,  its  second   edition,  enlarged  and   thoroughly 
success  of  his  mental  fruit  in  the  past,  and  the  pre-  j  revised,  brings  it  nearer  our  idea  of  a  model  text- 
sent  offer  seems  in  no  wise  an  exception  to  what  has    book  than  any  recently  published  treatise.     Though 
gone  before.     The  general  arrangement  of  the  vol-  \  numerous  additions  have  been  made,  the  size  of  the 
ume  is  the  same  as  in  the  first  edition,  but  every  part  :  work  is  not  materially  increased     The  main  trouble 
has  been  carefully  revii-ed,  and  much   new  matter    of  text-books  of  modern  times  is  that  they  are  too 


added.— Phila.  Med.  Times,  Feb.  ],  1S79. 


cumbersome.  The  student  needs  a  book  which  will 
furnish  him  the  most  information  in  the  shortest 
time.  In  every  respect  this  work  of  Ashhurst 


We   have   previously  spoken   of  Dr.    Ashhnrst's 

work  in  terms  of  praise.  We  wish  to  reiterate  those  i  tne  model  text-book-full,  comprehen.«ive~and"com- 
terms  here,  and  to  add  that  no  more  satisfactory  \  pact.-Kashville  Jour  of  Med  and  Sura  Jan  'TO 
representation  of  modern  surgery  has  yet  fallen  »»ry.,  jd.n.  /a. 


rgery   has   y 
In   point   of   judicial  fairness,  of 


The  favorable  reception  of   the  first  edition  is  a 


ower  of  condensation,  of  accuracy  and  conciseness  '<  guarantee  of  the  popularity  of  this  edition,  which  is 
f  expression  and  thoroughly  good  English,  Prof.  |  tresh  froln  the  edltor  s  Lands  with  many  enlarge- 
.shhurst  has  no  superior  among  the  surgical  writers  inents  and  improvements.  The  author  of  this  work 


perior  among  the  surg 
in  America.  —  Am.  Practitioner,  Jan.  1879. 

The  attempt  to  embrace  in  a  volume  of  1000  pages 
the  whole  field  of  surgery,  general  and  special, 
would  be  a  hopeless  ta?k  unless  through  the  most 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 
edition  to  the  latest  date.  Of  course  this  book  is  not 
designed  for  specialists,  but  as  a  course  of  general 
surgical  kiiou  ledge  and  for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  surpassed 
by  any  that  has  yet  appeared,  whether  of  home  or 
foreign  authorship.—^.  Carolina  Med.  Journal, 
Jan.  1879. 


is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  have 
gained  for  him  wide  reputation.  The  volume  now 
offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  can 
only  add  that  the  work  is  well  arrang.  d,  filled  with 
practical  matter,  and  contains  in  brief  and  clear 
language  all  that  is  necessary  t>  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  his  daily  routine 
practice.—  Mil.  Med  Journal,  Jan.  1879. 

The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  toon  after  the  publication  of  the  first 
one,  speaks  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gaiued  the  favor  of  stu- 
dents and  physicians.—  (Jinein.  Med.  Newsman.  '79 


f>RYANT  (THOMAS),  F.R.C.S., 

•*-'  Surgeon  to  Guy's  Hospital. 

THE  PRACTICE  OF  SURGERY.     Second  American,  from  the  Sec- 

ond  and  Revised  English  Edition.  With  Six  Hundred  and  Seventy  two  Engravings  on 
Wood.  In  one  large  and  very  handsome  imperial  octavo  volume  of  over  1000  large  and 
closely  printed  pages.  Cloth,  $6  ;  leather,  $7.  (Just  Ready.) 

This  work  has  enjoyed  the  advantage  of  two  thorough  revisions  at  the  hand  of  the  author  since 
the  appearance  of  the  first  American  edition,  resulting  in  a  very  notable  enlargement  of  size  and 
improvement  of  matter.  In  England  this  has  led  to  the  division  of  the  work  into  two  volumes, 
which  are  here  comprised  in  one,  the  size  being  increased  to  a  large  imperial  octavo,  printed  on 
a  condensed  but  clear  type.  The  series  of  illustrations  has  undergone  a  like  revision,  and  will 
be  found  correspondingly  improved. 

The  marked  success  of  the  work  on  both  sides  of  the  Atlantic  shows  that  the  author  has  suc- 
ceeded in  the  effort  to  give  to  student  and  practitioner  a  sou  id  and  trustworthy  guide  in  the 
practice  of  Surgery;  while  the  simultaneous  appearance  of  the  present  edition  in  England  and 
in  this  country  afi'ords  to  the  American  reader  the  benefit  of  the  most  recent  advances  made 
abroad  in  surgical  science. 

Another  edition  of  this  manual  having  been  called 
for,  the  author  has  availed  himself  of  the  opportunity 
to  make  no  few  alterations  in  the  substance  as  we.l 
as  in  the  arrangement  of  the  work,  and,  with  a  view 
to  its  improvement,  has  recast  the  materials  and  re- 
vised the  whole.  We  ourselves  are  of  the  opinion 

that  there  is  no  better  work  on  surgery  extant 

Cincinnati  Med.  News,  Match,  1879 

Bryant's  Surgery  has  been  favorably  received  from 
the  first,  and  evidently  grows  in  the  esteem  of  the 
profession  with  each  succeeding  edition.  In  glanc- 
ing over  the  volume  before  us  we  (iud  proof  in  almost 
every  chapter  of  the  thorough  revision  which  the 
work  has  undergone,  many  parts  having  been  cut 
out  and  replaced  by  matter  entirely  fresh.— N.  Y. 
Med.  Journ.,  April,  1879. 

Welcome  as  the  new  edition  is,  and  as  much  as  it 
Is  entitled  to  commendation,  yet  its  appearance  at 
this  time  is,  in  a  ceriain  seuse,  a  matter  of  regret,  as 
it  will  be  iu  competition  with  another  work,  lately 
issued  from  the  s*me  press.  Bat,  the  difficult  ta-k 
of  forming  a  judgment  as  to  the  relative  merits  of 
Bryant  and  Ashuurst  we  will  not  attempt,  but  pre- 
dict that,  considering  the  high  excellence  of  both, 
many  others  will  likewise  be  torced  to  hesitate  long 
iu  making  choice  between  them  — Cincinnati  Lan- 
cet and  Vliniu,  March  22,  Ib79. 


There  are  so  many  text-books  of  surgery,  FO  many 
written  by  skilled  and  dist.nguished  hands,  that  to  ob 
tain  the  honor  of  a  third  edition  in  England  is  no  light 
praise.  Mr.  Bryant  mi-rits  this,  by  clearness  of  style, 
»nd  good  judgment  in  selecting  the  operations  he  re- 
commends, in  bis  new  editions  he  goes  carefully  over 
the  old  grounds,  in  light  of  later  research.  On  these 
and  manj  allied  points,  Mr.  Bryant  is  a  culm  and  uu- 
partisan  observer,  and  bis  book  throughout  has  the 
great  merit  of  maintaining  the  true  scientific,  judicial 
tone  of  mind.— Med.  and  Sura.  Reporter,  March  22, 
1879. 

The  work  before  us  is  the  American  reprint  of  the 
last  London  edition,  and  has  the  advantage  over  the 
latter  in  being  of  more  convenient  size,  and  in  being 
compressed  into  one  volume.  The  author  has  rewrit- 
ten the  greater  part  of  the  work,  and  has  succeeded, 
in  the  amount  of  new  matter  added,  in  making  it  mark- 
edly distinctive  from  previous  editions.  A  few  extra 
pages  have  been  added,  and  also  a  few  new  illustrations 
introduced.  The  publishers  have  presented  the  work 
in  a  creditable  style.  As  a  concise  and  practical  manual 
of  British  surgery  it  is  perhaps  without  an  equal,  and 
will  doubtless  always  be  a  favorite  text-book  with  the 
student  and  practitioner. — N.  1\  Med.  Record,  March 
2-2.  isra 


28 


HENRY  C.  LEA'S  PUBLICATIONS — (Surgery). 


J£  RICES  EN  (JOHN  E. ), 

Professor  of  Surgery  in  University  College,  London,  ate. 

THE  SCIENCE  AND  ART  OF  SURGERY ;  being  a  Treatise  on  Sur- 
gical Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages: 
cloth,  $8  50  ;  leather,  $10  50.  (Now  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  science  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  pages  of  text, 
while  the  illustrations  have  undergone  a  marked  improvement.  A  hundred  and  fifty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seventh  edition  is  before  the  world  as  the  last 
word  or  surgical  science.  There  may  be  monographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  practitioners  to 
read  it,  for  it  has  been  a  peculiar  province  of  Mr. 
Erichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  guide  at  the  bedside.—  Am  Practi- 
tioner, April,  1878. 

It  is  no  iile  compliment  to  say  that  this  is  the  best 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  iis 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  h.is  incorporated 
into  this  edition  every  recent  improvement  in  the 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatiugly  aver  that  we  know  of  uo  other  single 
work  where  the  student  and  practitioner  can  gain  at 
oncesoclear  an  insight  iuto  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.—  London  Lancet,  Feb.  14,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text-book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  one  hun- 
dred and  fifty  new  illustrations  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  pathological  processes.  So  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — Ifed.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Surgery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  nonu 
which  in  all  points  has  satisfied  us  so  well  as  thn  classic 
treatise  of  Krichsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  his  unsurpassed  grasp 
of  his  subject,  and  vast  clinical  experience,  quality  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  another  edi- 
tion.— Med.  and  Surg.  Jiepurtrr,  Feb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up.  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
beeu  made  in  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn.  The  author  highly  appreciates  the 
favor  wilh  which  his  work  has  been  recehed  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  his  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has] succeeded  admirably,  must,  we  think,  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  Y.Med.  Journal, 
Feb.  1878. 

Erichsen  has  stood  so  prominently  forward  for 
years  as  a  writer  on  Surgery,  that  his  reputation  is 
world  wide,  and  his  name  is  as  familiar  to  the  med- 
ical student  as  to  the  accomplished  and  experienced 
surgeon.  The  work  is  not  a  reprint  of  former  edi 
tions,  but  has  in  many  places  been  entirely  rewrit- 
ten. Recent  improvements  in  surgery  have  not  es- 
caped his  notice,  various  new  opennions  have  been 
thoroughly  analyzed,  and  their  merits  thoroughly 
discussed.  One  hundred  and  fifty  new  wood-cuts 
add  to  the  value  of  this  work. — N.  O.  Med.  and  Surg. 
Journal,  March,  1878. 


H 


;OLMES  (TIMOTHY),  M.D., 
Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE. 

anmA  npt.n.vo  volume  of  nearlv  1  Oflfl  nntrps    wit.h  4.11  illnatnitintiH      f!lr 


In  one  band- 


RGE,  A  AI.      n  one     an- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7. 
(Just  Issued.) 


This  is  a  work  which  has  been  looked  for  on  both 
sides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  of  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  upon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner.  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  justifies  the  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  and  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 
to  bring  it  wit  bin  its  proper  limits  has  1101  impaired 


its  force  and  distinctness.— .y.  F.  Mid.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  general  practitioner  who  has  not  the 
time  to  give  attention  to  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  no  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  an'd 
practical  account  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and.especially  as  a  l&Ttl- 
book.—CincinriatiMed.  ffews,  April,  1S76. 


ASHTON  ON  THE  DISEASES,  INJURIES,  AND  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  Constipation.  Second 
American,  from  the  fourth  and  enlarged  London 
Edition.  With  illustrations.  In  one  8vo.  vol.  ol 
287  pages,  cloth,*;}  25. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Snigery.  One 
12mo.  vol.  of  3S3pag9s,  with  181  wood-cuts.  Cloth, 
$175. 


HENRY  C.  LEA'S  PUBLICATIONS — (Ophthalmology). 


29 


fJAMILTON  (FRANK  H.),  M.D., 

•*•-*-  Professor  of  Fractures  and  Dislocations,  Ac.,  in  Bellevue  Hasp.  Med.  College,  New  For*. 

A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCJ  - 

TIONS.  Fifth  edition,  revised  and  improved.  In  one  large  and  handsome  octavo  volume 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $5  75;  leather,  $6  75.  (Lately  Issued.) 
This  work  is  well  known,  abroad  as  well  as  at  home,  asthe  highest  authority  on  its  important 
subject — an  authority  recognized  in  the  courts  as  well  as  in  the  schools  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress for  the  speedy  appearance  of  a  translation  in  Germany.  The  repeated  revisions  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  most  careful  consid- 
eration to  every  portion  of  the  volume,  and  he  has  sedulously  endeavored  in  the  present  issue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience,  and  to  incorporate  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  issue  of  the  fourth  edition.  It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
to  the  typographical  execution,  and  the  volume  is  presented  to  the  profession  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 


There  is  no  better  work  on  the  subject  in  existence 
than  that  of  Dr.  Hamilton .  It  should  be  in  the  posses- 
sion of  every  general  practitioner  and  surgeon. —  The 
Am.  Journ.  of  Obstetrics,  Feb.  1876. 

The  value  of  a  work  like  this  to  the  practical  physi- 
cian and  surgeon  can  hardly  be  over-estimated,  and  the 
necessity  of  having  such  a  book  revised  to  the  latest 
dates,  not  merely  on  account  of  the  practicalimportance 


of  its  teachings,  but  also  by  reason  of  the  medico-legal 
bearings  of  the  cases  of  which  it  treats,  and  which  have 
recently  been  the  subject  of  useful  papers  by  Dr.  Hamil- 
ton and  others,  is  sufficiently  obvious  to  every  one.  The 
present  volume  seems  to  amply  fill  all  the  requisites. 
We  can  safely  recommend  it  as  the  best  of  its  kind  in 
the  English  language,  and  notexcelled  in  any  other. — 
Journ.  of  Ntrvous  and  Mental  Disease,  Jan.  1876. 


B 


ROWNE  (EDGAR  A.), 

Surgeon  to  the.  Liverpool  Eye  and  Ear  Infirmary,  and  to  the  Dispensary  for  Skin  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty-five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     (Now  Ready.) 


This  capital  little  work  should  be  in  the  hands  of 
ev-ry  medical  student,  and  we  had  almostsaid  every 


could  scarcely  fail  of  understanding  them.    Equally 
satisfactory  are  the  directions  for  the  use  of  the  in- 


general  practitioner.     Its  explanation  of  the  optic.il    strument  and  the  suggestions  to  aid  in  interpreting 
principles  on  which  the  ophthalmoscope  is  founded,  j  what  is  seen. — Dttroit  ifed.  Journ.,  ftov.  1877. 
is  so  clear  and  simple  that  the  most  stupid  reader  ] 

BARTER  (R.  BRUDENELL),  F.R.C.S., 

Ophthalmic  Surgeon  to  St.  George  s  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.  Edit- 
ed, with  test-types  and  Additions,  by  JOHN  GREEN,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  $3  75.  (Just 
Issued. ) 

It  would  be  difficult  for  Mr.  Carter  to  write  an  unin-  ,  manner,  easy  of  comprehension,  and  hence  the  more 
structive  book,  and  impossible  for  him  to  write  an  un-  ]  valuable.   We  would  especially  commend,  however,  as 


interesting  one.  Even  on  subjects  with  which  he  is  not 
bound  to  be  familiar,  hecan  discourse  with  a  rare  degree 
of  clearness  and  effect.  Our  readers  will  therefore  not 
be  surprised  to  learn  that  a  work  by  him  on  the  Diseases 
of  the  Eye  makes  a  very  valuable  addition  to  ophthal- 
mic literature.  .  .  .  The  book  will  remain  one  useful 
alike. to  the  general  and  the  special  practitioner.— ion 
don  Lancet,  Oct.  30,1875. 

It  is  with  great  pleasure  that  we  can  endorse  the  work 
as  a  most  valuable  contribution  to  practical  ophthal- 
mology .Mr.  Carter  never  deviates  from  the  end  he  has 
in  view,  and  presents  the  subject  in  a  clear  and  coucis* 


worthy  of  high  praise,  the  manner  in  which  the  thera- 
peutics of  disease  of  the  eye  is  elaborated,  for  here  the 
author  is  particularly  clear  and  practical,  where  other 
writers  are  unfortunately  too  often  deficient.  The  final 
chapter  is  devoted  to  a  discussion  of  the  usesand  selec- 
tion of  spectacles,  and  is  admirably  compact,  plain,  and 
useful,  especially  the  paragraphs  on  the  treatment,  of 
presbyopia  and  myopia.  In  conclusion,  our  thanks  are 
due  the  author  for  many  useful  hintsin  the  great  sub- 
ject of  ophthalmic  surgery  and  therapeutics,  afield 
where  of  late  years  we  glean  but  a  few  grains  of  sound 
wheat  from  a  inassof  chaff. — New  York  Medical  Kecord, 
Oct.  23, 1875. 


w 


'ELLS  (J.SOELBERG), 

Professor  of  Ophthalmology  in  King's  College  Hospital,  Ac. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Fourth  and  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
engravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.  In  one  large  and  very  handsome  octavo  volume.  (Preparing.) 

"  A  URENCE  (JOHN  Z.),  F.  R.  C.S., 

Editor  of  the  Ophthalmic  Review,  Ag. 

A  HANDY-BOOK  OF  OPHTHALMIC  SURGERY,  for  the  use  of 

Practitioners.  Second  Edition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  cloth,  $2  75. 

r  A  WSON  (GEORGE), F.R.C.S.  Engl., 

Assistant  Surgeon  to  the  Royal  London  Ophthalmic  Hospital,  Woorflelds,  Ac. 

INJURIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 
diate and  Remote  Effects.  With  about  one  hundred  illustrations.  In  one  very  hand- 
some octavo  volume,  cloth,  $3  50. 


30 


HENRY  C.  LEA'S  PUBLICATIONS — (Medical  Jurisprudence). 


T>URNETT  (CHARLES  H.),  MA  ,M.D., 

•*-*  Aural  Surff  to  the  Prttb.  Uotp.,  Surgeon-in-ihargt,  of  the  Jnfir  for  Dig.  of  the  Ear,  Phila. 

THE   EAR,  ITS    ANATOMY,  PHYSIOLOGY,  AND    DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  j  leather, 
$5  50.  (Just  Ready.) 

Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  wouldseem  to  render  desirable  a  new  woik  in  which  nil  the  re- 
sources of  the  most  advanced  science  should  be  placed  at  the  disposal  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  labors  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  tbis  department. 

On  account  of  the  great  advance*  which  have  been  |  As  the  title  of  the  work  indicates,  this  volume 
made  of  late  years  in  otology,  and  of  the  increased  j  treats  of  the  anatomy  and  physiology  of  the  ear,  as 
interest  manifested  in  it,  the  medical  profession  will  ,  well  as  of  its  diseases,  and  the  author  has  taken 
welcome  this  new  work,  which  presents  clearly  and  •  special  pains  to  make  this  difficult  and  complicated 
concisely  its  present  aspect.  whiUt  clearly  indi-  •  matter  thoroughly  clear  and  intelligible.  The  book 
eating  the  direction  in  which  further  researches  can  ',  is  designed  ecpecially  for  the  use  of  students  aud 
be  most  profitably  carried  on.  Dr.  Barn  tt  from  his  !  general  practitioners,  and  places  at  their  dis] H.i-al 
own  matured  experience,  and  availing  himself  of  much  valuable  material.  Such  a  book  as  tbe  pre- 
tbe  observations  and  discoveries  of  others,  has  pro-  seat  one,  we  think,  ha*  long  been  needed,  aud  we 
daced  a  work,  which  as  a  text-book,  stands  facile  \  may  congratulate  the  author  on  his  success  in  fill- 
princfps  in  our  language.  We  had  marked  several  j  ing  the  gap.  Both  student  and  practitioner  can 
passages  as  well  worthy  of  quotation  and  the  alien-  i  study  the  work  with  a  gn  at  deal  of  benefit.  It  is 
tion  of  the  general  practitioner,  l>nt  their  number  and  ;  profusely  aud  beautifully  illustrated.— A.  Y.  Uot- 
the  space  at  our  command  forbid.  Perhaps  it  is  bet-  \  pital  Gazette,  Oct  15,  1677. 
ter,  as  the  book  ought  to  be  in  the  hands  of  every 

medical  student,  and  its  study  will  well  repay  the  :  The  appearance  of  this  book  is  another  proof  of  th« 
busy  practitioner  in  the  pleasure  he  will  derive  from  rapidly  increasing  amount  of  honest,  valuable  work 
the  agreeable  style  in  which  many  otherwise  dry  that  is  now  being  dune  in  the  various  branches  of 
and  mostly  unknown  subjects  are  treated.  To  the  !  medical  science  in  this  country  Dr.  Burnett  is  to  be 
specialist  the  work  is  of  the  highest  value,  and  his  commended  for  having  written  the  best  book  on  the 
sense  of  gratitude  to  Dr.  Burnett  will  we  hope,  be  subject  in  the  English  language,  and  especially  for 
proportionate  to  tbe  amount  of  benefit  be  can  obtain  •  the  care  and  attention  he  has  given  to  the  scientific 
from  the  careful  study  of  the  book,  and  a  constant  side  of  the  subject.— A.  1".  JMed.  Journ.,  Dec.  Is77. 
reference  to  its  trustworthy  pages.  —  Edi/iiiu  gh 
Med.  Jour.,  Aug.  1878. 

fTAYLOE  (ALFRED    S.),M.D., 

•*  Lecturer  on  Med.  Juritp.  and  Chemistry  in  Quy'g  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.  Third  American,  from  the  Third  and  Revised  English  Edition.  In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.  (Just  Issued.) 


The  present  is  based  upon  the  two  previous  edi- 
tions; -'but  the  complete  revision  rendered  necessary 
by  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition.  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medico-legal  testimony  (and  what  -ne  is  not?),  so  that 
all  that  is  required  to  be  known  about  tbe  present 
book  is  that  the  author  has  kept  it  abreast  wiih  the 
times.  What  makes  it  now,  as  always,  especially 
valuable  to  the  practitioner  is  its  conciseness  ana 
practical  character,  only  those  poisonous  substances 


being  described  which  give  rise  to  legal  luvestiga- 
tions.  —  The  Clinic,  Nov.  6,  1875. 

Dr.  Taylor  has  brought  to  bear  on  tbe  compilation 
of  this  volume,  stores  of  learning,  experience,  and 
practical  acquaintance  with  iiis  subject,  probably  fur 
beyond  wha;  any  other  living  authority  on  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fuily 
sustained  his  reputation  by  the  consummate  skill 
and  legal  acumen  he  has  di.-played  in  the  arrange- 
ment of  tne  subject-matter,  aud  the  result  is  a  work 
on  Poisons  whicu  will  be  indispensable  to  every  stu- 
dentor  practitioner  in  law  aud  medicine. — TUe  Dub- 
lin Journ.  of  Med  Set.,  Oct.  167.}. 


B 


Y  THE  SAME  AUTHOR. 


MEDICAL  JURISPRUDENCE.   Seventh  American  Edition.   Edited 

by  JOHH  J.  REBSE,  M.D.,  Prcf.  of  Med.  Jurisp.  in  the  Univ.  of  Penn.     In  one  large 
octavo  volume  of  nearly  900  pages.     Cloth,  $5  00  ;  leather,  $6  00.     (Lately  Issued.) 
To  the  members  of  the  legal  aud   medical  profes-    best  authority  on  this  specialty  in  our  language.  On 
sion,  it  is  unnecessary  to  say  anything  corn  mend  a-    this  point,  however,  we  will  say  that  we  consider  Dt. 
tory  of  Taylor's  Medical  Jurisprudence.    We  might  !  Taylor  to  be  the  safest  medico-legal  authority  to  fol- 
as  well  undertake  to  speak  of  tbe  merit  ofCbitty'e    low,  in  general,  with  which  we  are  acquainted  in  any 
Pleadings. — Chicago  Legal  ffttot,  Oct.  16,  1873.         j  language. —  fa.  Clin.  Record,  Nov.  1S73. 

It  i.  beyond  question  the  most  attractive  as  well  j  Thislastedition  ofthe  Manual  isprobably  the  best 
as  most  reliable  manual  of  medical  jurisprudence  ;  of  all  ag  it  contains  more  material  and  U  forked  up 
published  in  the  English  langnage.—^w.  Journal ,  to  the  ,ateg,  virtws  of  the  anlhor  a!  expressed  in  tb« 
of  Syphilography,  Oct.  1873.  Ugt  editioa  of  the  Principles.  Dr.  Keese,  the  editor 

It  is  altogether  superfluous  for  us  to  offer  anything  of  the  Manual,  has  done  everything  to  make  his 
in  behalf  of  a  work  on  medical  jurisprudence  by  an  work  acceptable  to  his  medical  countrymen.  — A.  1". 
author  who  isalmost  universally  esteemed  lobe  the  )  Med.  Jlecord,  Jan.  lo,  1874. 


B 


Y  THE  SAME  AUTHOR. 


THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 
volumes,  cloth,  $10  00  ;  leather,  $12  00 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  A  mer- 
ican  profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


HENRY  C.  LEA'S  PUBLICATIONS — (Miscellaneous). 


31 


THOMPSON  (SIR  HENRY), 

•^-  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hoapital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.  Second  American  from  the  Third  English  Edition.  In  one  neat 
octavo  volume.  Cloth,  $2  25.  (Just  issued.) 

JDF  THE  SAME  AUTHOR. 

ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  50. 
(Lately  Published.) 

ROBERTS  (  WILLIAM),  M.D., 

•'*-*'  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE   ON  URINARY  AND  RENAL  DIS 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  Edition.  In  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  cloth,  $4  50.  (Lately 
Published.) 

fTUKE  (DANIEL  HACK],  M.D., 

A-  Joint  author  of  "  The  Manual  of  Psychological  Medicine,"  Ac. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  tLe 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  (Lately  Issued.) 

-DLANDFORD  (O.  FIELDING),  M.D.,  F.R.C.P., 

J-*  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Ac. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  ISAAC  RAY,  M.  D.  In  one  very 
handsome  octavo  volume  of, 471  pages;  cloth,  $3  25. 


It  satisfies  a  want  which  must  have  been  sorely 
feltby  the  busy  general  practitioners  of  thin  country. 
It  takes  the  form  of  a  manual  of  clinical  description 
of  the  various  forms  of  insanity,  with  a  description 
of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  givingit  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


actually  seen  in  practice  and  the  appropriate  treat 
ment  for  them,  we  find  in  Dr.  Blaudford's  work  a 
considerable  advance  over  previous  writings  on  tl  e 
subject.  His  pictures  of  the  various  forms  of  mortal 
disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  in 
oidinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extends)in  any  other. — London 
Practitioner,  Feb.  1871. 


EA  (HENRY  C.). 

'SUPERSTITION  AND  FORCE:  ESSAYS  ON  THE  WAGER  CF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.  Third  Revised 
and  Enlarged  Edition.  In  one  handsome  royal  12mo.  volume  of  552  pages.  Cloth, 
$2  50.  (Just  Ready.) 


The  appearance  of  a  new  edition  of  Mr.  Henry  C. 
Lea's  "  Superstition  and  Force"  is  a  s  gn  that  our 
highest  scholarthip  is  not  without  honor  in  its  na- 
tive country.  Mr.  Lea  has  met  every  fresh  demand 
for  his  wort  with  a  careful  revision  of  it,  and  the 
present  edition  is  not  only  fuller  and,  if  possible, 
more  accurate  than  either  of  the  preceding,  but, 
from  the  thorough  elaboration  is  more  like  a  har- 
monious c  incur;  and  less  like  a  batch  of  studies. — 
The  Motion,  Aug.  1,  1878. 

Many  will  ba  tempted  to  say  that  this,  like  the 
"Decline  and  Fall,"isoue  of  the  uucriticizable  books 
Its  facts  are  innumerable,  its  deductions  simple  and 
inevitable,  and  its  che-oaux-dv-frise  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial iu  it  to  provoke  assault.  The  author  is  no 


polemic.  Though  he  obviously  feels  and  thinks 
strongly,  he  succeeds  in  attaining  impartiality. 
Whet)  er  looked  on  as  a  picture  or  a  mirror,  a  work 
such  as  this  has  a  lasting  value.  —  Lippincott's 
Magazine,  Oct.  1878. 

Mr.  Lea's  curious  historical  monographs,  of  which 
oue  i.f  the  most  important  is  here  reproduced  in  an 
enlarged  form,  have  given  him  an  unique  position 
among  English  and  American  scholars.  He  is  dis- 
tinguished for  his  recondite  and  affluent  learning, 
his  power  of  exhaustive  historical  analysis,  il.e 
breadth  and  accuracy  of  his  researches  among  the 
rarer  sources  of  knowledge,  the  gravity  and  temper- 
ance of  his  statements,  combined  with  singular 
earnestness  of  conviction,  and  his  warm  attachment 
to  the  cause  of  human  freedom  and  intellectual  pro- 
gress.—^. Y.  Tribune,  Aug.  9,  1878. 


BY  THE  SAME  AUTHOR.    (Lately  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 
PORAL POWER— BENEFIT  OF   CLERGY— EXCOMMUNICATION.     In   one   large 
royal  12mo.  volume  of  516  pp.;  cloth,  $2  75. 
The  story  was  never  told  mora_calaily  or  with    aasapecnliarimportancefortheEnglishsttident,aEd 


greater  learning  or  wiser  thought.  We  doubt,  indeed, 
if  any  other  study  of  this  field.can  be  compared  with 
tais  for  clearness,  accuracy,  and  power.  —  Chicago 
Examiner,  Dec.  1870. 

Mr.  Lea's  latest  work, "  Studies  in  Church  History," 
fully  sustains  the  promise  of  the  first.  It  deals  with 
three  subjects — the  Temporal  Power,  Benefit  of 
Clergy,  and  Excommunication,  the  record  of  which 


Is  a  chapter  on  Ancient  Law  likely  tobe  regarded  as 
Unal.  We  can  hardly  pass  from  our  mention  of  such 
works  as  these — with  which  that  on  "Sacerdotal 
0  ilibacv"  should  be  included — without  noting  r  he 
literary  phenomenon  that  the  head  <>f  one  of  the  first 
American  houses  is  also  the  writer  of  some  of  it?  most 
original  books. — London  Athtnaum,  Jan.  7,  1871. 


32 


HENRY  C.  LEA'S  PUBLICATIONS. 


INDEX   TO    CATALOGUE. 


PAHB 

American  Journal  of  the  Medical  Sciences  .  1 
Abstract,  Mouthly,  of  the  Med.  Sciences  .  .  3 

Allen's  Anatomy 7 

Anatomical  Atlas,  by  Smith  and  Horner  .  .  7 
Ashton  on  the  Rectum  and  Anus  .  .28 

Attfleld's  Chemistry 11 

Ash  well  on  Diseases  of  Females         .        .        .23 

Ashhur.-U'n  Surgery 2.3 

Browne  on  Ophthalmoscope 29 

Browne  on  the  Throat IS 

Burnett  on  the  Ear 30 

Barnes  on  Diseases  of  Women  .  .  .  .22 
Bellamy's  Surgical  Anatomy  ....  7 
Bryant  s  Practical  Surgery  ....  27 

Bloxam's  Chemistry 11 

Blandt'ord  on  Insanity 31 

Basham  on  Renal  Diseases IS 

Brinton  on  the  Stomach  .....  IS 
Barlow's  Practice  Ql  Medicine  .  .  14 

Bowman's  (John  E.)  Practical  Chemistry .  .  10 
Bowman's  (John  E.)  Medical  Chemistry  .  .  10 

Bristowe's  Practice 16 

Bamstead  on  Venereal 19 

gumstead  and  Cullerier's  Atlas  of  Venereal  .  19 
Carpenter's  Human  Physiology  .  .  8 

C-trpenter  on  the  Use  and  Abuse  of  Alcohol  .  13 
Cornil  and  Ranvier  .'..;'.  .  .14 
Carter  on  the  Eye  .  .  . •  *  /•  .  .  .29 

Cleland's  Dissector 7 

Classen's  Chemistry 10 

Clowes'  Chemistry 11 

Century  of  American  Medicine  ....  5 
Chadwick  on  Diseases  of  Women  .  .  .23 
Charcot  on  the  Nervous  System  .  .  .  .17 
Chambers  on  Diet  and  Regimen  .  .  .  .  18 
Chambers's  Restorative  Medicine  .  .  .  18 
Christison  and  Griffith's  Dispensatory  .  .  13 
Churchill's  Svstem  of  Midwifery  .  .  .  21 
Churchill  on  Puerperal  Fever  .  .  .  .21 
Condie  on  Diseases  of  Children  .  .  .  .21 
Cooper's  (B.  B.)  Lectures  on  Surgery  .  ,  25 
Cullerier's  Atlas  of  Venereal  Diseases  .  .  79 
Cyclopaedia  of  Practical  Medicine  .  .  .14 
Dalton's  Human  Physiology  ....  9 

Davis's  Clinical  Lectures 14 

Dewees  on  Diseases  of  Females  .  .  .  .21 
Drnitt's  ModernSnrgery  .  ...  26 

Dnnglison's  Medical  Dictionary  ...  4 
Dunglison's  Human  Physiology  ...  9 
Eliis's  Demonstrations  in  Anatomy  ...  7 
Erichsen's  System  of  Surgery  .  .  .  .28 

Emmet  on  Diseases  of  Women 23 

Farquharson's  Therapeutics          ....     11 

Fenwick's  Diagnosis 14 

Finlayson's  Clinical  Diagnosis  .  .  .  .17 
Flint  on  Respiratory  Organs  ....  IS 

Flint  on  the  Heart 18 

Flint's  Practice  of  Medicine 15 

Flint's  Essays 15 

Flint's  Clinical  Medicine 15 

Flint  on  Phthisis 18 

Flint  on  Percussion IS 

Fothergill's  Handbook  ofTreatroent  .  .  .16 
Fothergill's  Antagonism  of  Therapeutic  Agents  .  16 
Fjwnes's  Elementary  Chemistry  .  •  .  10 
Fox  on  Diseases  of  the  Skin  .  .  .  .20 
Fuller  on  the  Lungs,  &c.  .  .  .  18 

Green's  Pathology  and  Morbid  Anatomy  .        .    14 

Gibson's  Surgery 25 

Glnge's  Pathological  Histology,  by  Leidy  .        .     14 

Gray's  Anatomy 6 

Galloway's  Analysis 10 

Griffith's  (R.  E.)  Universal  Formulary        .        .    12 

Gross  on  Urinary  Organs 26 

Gross  on  Foreign  Bodies  in  Air-Palaces  .  .  26 
Gross's  Principles  and  Practice  of  Surgery  .  26 

Habershon  on  the  Abdomen 16 

Hamilton  on  Dislocations  and  Fractures  .  .  29 
Hartshorne's  Essentials  of  Medicine  .  .  .15 
Hartshorne'a  Conspectus  of  the  Medical  Sciences  f> 
Hartshorne's  Anatomy  and  Physiology  .  .  J> 
Hamilton  on  Nervous  Diseases  .  .  .  .17 
Heath's  Practical  Anatomy  ....  7 
Hoblyn's  Medical  Dictionary  ....  4 
Hodge  on  Women 21 


dodge's  Obstetrics 

Holland's  Medical  Notes  and  Reflections  . 

Holmeit's  Surgery 

Holden's  Laudmarks  .         ... 

lorner's  Anatomy  and  Histology 


MM 

24 
.  14 

28 

.  6 
.  7 


Hudson  on  Fever   .......     18 

Hill  on  Venereal  Diseases    .....     19 

Hillier's  Handbook  of  Skin  Diseases          .        .     20 
(ones  (C.  HandBeld)  on  Nervous  Disorders     .     IS 
Kirkes'  Physiology       .         .....       8 

Knapp's  Chemical  Technology   .        .         .        .     1 

Lea's  Superstition  and  Force  .        .        .3 

Lea's  Studies  in  Church  History          .  .31 

Lee  on  Syphilis      .......     1 

Lincoln  on  Electro-Therapeutics         .        .        .     IS 
Leishman's  Midwifery  ......    25 

La  Roche  on  Yellow  Fever  .....     14 

La  Roche  on  Pneumonia,  &c  .....     13 

Laurence  and  Moon's  Ophthalmic  Surgery         .     29 
Lawson  on  the  Eye  ...  .29 

Lehmann's  Physiological  Chemistry,  2  Tols.     .      9 
Lehmanu's  Chemical  Physiology        ...       9 
Ludlow's  Manual  of  Examinations    ...       5 
Lyons  on  Fever     .......     IS 

Medical  News  and  Library  ..... 

Meigs  on  Puerperal  Fever    .....     5 

Miller's  Practice  of  Surgery        ....     2 

Miller's  Principles  of  Surgery     .        .        .        .25 

Montgomery  on  Pregnancy          .        .        .        .21 

Neill  and  Smith's  Compendium  of  Med.  Science      '• 
Neligan's  Atlas  of  Diseases  of  the  Skin      .        .     2 
Obstetrical  Journal       ......     - 

Parry  on  Extra-Uterine  Pregnancy      .        .        .2 
Pavy  on  Digestion        ......     1 

Pavy  on  Food          .......     1 

Parrish's  Practical  Pharmacy     .        .  .     1 

Pirrie's  System  of  Surgery  .....     25 

Playfair's  Midwifery     ......     21 

Quain  and  Sharpey's  Anatomy,  by  Leidy  .        . 
Roberts  on  Urinary  Diseases         ....     2 

Ramsbotbam  on  Parturition         .        .        .        .25 

Remsen's  Principles  of  Chemistry 

Rigby's  Midwifery         ......     21 

Rodwell's  Dictionary  of  Science..        ...       5 

Stimsou's  Operative  Surgery        ....     2 

Swayne's  Obstetric  Aphorisms    ....     2 

Seller  on  the  Throat  .     ......     18 

Sargent's  Minor  Surgery       .....     2 

Sharpey  and  Qnain's  Anatomy,  by  Leidy  . 

Skey's  Operative  Surgery     .....    25 

Slade  on  Diphtheria      ......     IS 

Schafer's  Histology       ......       7 

Smith  (J.  L.)  on  Children      .....     21 

Smith  (H.  H.)  and  Homer's  Anatomical  Atlas   .       7 
Smith  (Edward)  on  Consumption        .         .        .18 
Smith  on  Wasting  Diseases  in  Children      .        .     21 
Stilie's  Therapeutics      ......     12 

Siille  &  Maisch's  Dispensatory    .        .        .        .1 

Starges  on  Clinical  Medicine        .        .        .        .'1 

Stokes  on  Fever    .......     14 

Tanner's  Manual  of  Clinical  Medicine        .        •      5 
Tanner  on  Pregnancy    ......     24 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med   Jurisp    :U 

Taylor  on  Poisons          ......     30 

Tuke  on  the  Influence  of  the  Mind      .        .        .31 
Thomas  on  Diseases  of  Females          .  .     22 

Thompson  on  Urinary  Organs      .        .        .        .     S 

Thompson  on  Stricture  ......    31 

Todd  on  Acute  Diseases        .....     1 

Woodbury's  Practice     ......     IS 

Walshe  on  the  Heart    ......     1 

Watson's  Practice  of  Physic       .        .        .        .15 

Wells  on  the  Eye  .......    29 

West  on  Diseases  of  Females      .        .        .        .20 

West  on  Diseases  of  Children      .  .    20 

West  on  Nervous  Disorders  of  Children     .         .    21 
What  to  Observe  in  Medical  Cases     .  .14 

Williams  on  Consumption   .....     18 

Wilson's  Human  Anatomy  .....       7 

Wilson  on  Diseases  of  the  Skin  ....    20 

Wilson's  Plates  on  Diseases  of  the  Skin    .        .     20 
Wilson's  Handbook  of  Cutaneous  Medicine      .    20 
Wbhler's  Organic  Chemistry       ....      9 

Winckel  on  Childbed    .     '  ....    23 


HENRY  C.  LEA— Philadelphia. 


3  1970007180935 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

Return  this  material  to  the  library 

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ILL 

DEC  1  5  1999 


A  000  548  273  2 


WQ160 
PT22t 
18?8 
Playfair,  William  S 

A  treatise  on  the  science  and 

practice  of  midwifery 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


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